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UNITED STATES OF AMERICA. 



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PRACTICAL SURGERY: 



INCLUDING 



SURGICAL DRESSINGS, BANDAGING, 
LIGATIONS AND AMPUTATIONS. 



/ 



BY 



J. EWING MEARS, M.D., 

iMONSTRATOR OF SURGERY IN JEFFERSON MEDICAL COLLEGE, PROFESSOR OF 
ANATOMY AND CLINICAL SURGERY IN PENNSYLVANIA COLLEGE OF DENTAL 
SURGERY, SURGEON TO ST. MARY'S HOSPITAL, GYNAECOLOGIST TO 
JEFFERSON MEDICAL COLLEGE HOSPITAL, ONE OF THE VICE- 
PRESIDENTS OF THE PATHOLOGICAL SOCIETY OF 
PHILADELPHIA, FELLOW OF THE COLLEGE 
OF PHYSICIANS OF PHILADELPHIA, 
ETC. 







WITH 
TWO HUNDRED AND TWENTY-SE 
ILL USTRA TIONS. 



PHILADELPHIA: 

LINDSAY & BLAKISTON. 

1878. 





Entered according to Act of Congress, in the year 1S78, by 

J. EWING MEAES, M.D., 
In the office of the Librarian of Congress, at Washington. 



COLLINS, PRINTER. 



TO 

SAMUEL D. GROSS, M.D., LL.D., D.C.L. Oxon., 

PROFESSOR OF SURGERY IN JEFFERSON MEDICAL COLLEGE, 

WHOSE EMINENT SERVICES 

AS 

AUTHOR, TEACHER, AND PRACTITIONER 

HAVE CONFERRED 

HONOR UPON HIS COUNTRY, HIS PROFESSION, AND HIMSELF, 

Ips §flok 

IS GRATEFULLY INSCRIBED 
BY 

THE AUTHOR. 



PREFACE 



This book has been written in response to the request 
of students who have been from time to time under the 
instruction of the author, and who have expressed a 
desire for a work which should embrace in a condensed 
form the subjects herein treated of. It has been the 
endeavor of the author to present these subjects in as 
concise a manner as possible, and at the same time to 
omit nothing which might be deemed necessary to render 
the instruction complete. While he has aimed to em- 
body chiefly the results of his own experience as a 
teacher and as a practitioner, he has not hesitated to 
make use of the standard text-books on surgery, and of 
such works as are devoted to the consideration of the 
special topics presented in this. 

With a few exceptions, the illustrations are reproduc- 
tions from the works of Gross, H. H. Smith, Stephen 

(v) 



•■ 



vi preface. 

Smith, Ashhurst, Packard, Maunder, Heath, Bel- 
lamy, and Bernard and Huette. The anatomical 
relations of the arteries are largely those which are given 
in " Gray's Anatomy," the correctness of which has 
been verified by dissections and operations. 

Messrs. Gemrig and Kolbe, instrument-makers, of this 
city, and Messrs. Stholmann, Pfarre & Co., of New York, 
have placed the author under obligations for the loan of 
cuts of instruments. 

To Dr. John W. Barr his thanks are especially due 
for valuable aid in correcting the proof of the work. 



Philadelphia, 1429 Walnut St. 
October, 1878. 



CONTENTS 



PART I. 

SURGICAL DRESSINGS. 



Compresses ..... 

Plasters ..... 

Poultices or Cataplasms . 

Methods of Irrigation 

Sponges ..... 

Instruments used in Dressing Wounds 

Dressing a "Wound 

The Antiseptic System of Dressing Wounds 

Splints 



PAGE 

13 

18 
20 
22 

23 
24 
28 
30 

35 



PART II. 



BANDAGING. 



The Simple Bandage or Roller 












• 36 


for the Head, Body, Extremities 












38 


for the Hand 












39 


Bandages of the Head . 












42 


of the Trunk . . / 












49 


of the Extremities 












56 


of the Superior Extremity . 












56 


of the Inferior Extremity . 












62 



(vii) 



CONTENTS. 



General Bandages .... 

The Compound Bandages 
Mayor's System of Handkerchief Dressings 
Immovable Bandages . . - . 



PAGE 

65 
69 

71 

75 



PART III. 

LIGATIONS. 

Positions of the Knife 

Incisions 

Closure of Wounds 

Sutures 

Operations upon the Living and Dead Subjects 

Instruments used in the Ligation of Arteries . 

Operations for the Ligation of Arteries . 

Ligation of Special Arteries .... 



82 
84 
85 
85 
S7 







PART IV. 




AMPUTATIONS. 




Instruments used in Amputations .... 


• 173 


Methods of Amputation ...... 


. 180 


Special Amputations ...... 


. . 196 


Lower Extremity . . . . . 


. . 196 


Upper Extremity . . . 


. 241 


Index ......... 


• 275 



PRACTICAL SURGERY. 



Practical Surgery may be divided conveniently into 
two parts : First, that part which relates to the preparation 
and application of surgical dressings — mechanical ; and, 
second, that which embraces surgical operations — the use 
of cutting instruments and the production of wounds — 
operative. 



PART I. 

SURGICAL DRESSINGS. 

Under this term may be included all appliances which 
are employed in the treatment of wounds, made either by 
the surgeon in performing operations, or those which are 
caused by injuries. 

They consist, in general, of Compresses, Plasters, Poul- 
tices, Splints, and Bandages, and are prepared in such 
manner as to fulfil the indications presented in each indi- 
vidual case. ^ 

Compresses are folded pieces of various materials, 
such as lint, charpie, cotton, wool, oakum, muslin, linen, 
etc., which are placed upon a part and retained by means 
of bandages. 

2 ( x 3) 



14 SURGICAL DRESSINGS. 

Lint is a soft, flocculent substance prepared by scraping 
the surface of a piece of old linen. That known as patent 
lint is made by machinery. Recently another form of 
lint, made from paper and called paper- lint, has been 
prepared, which possesses remarkable absorbent proper- 
ties. Lint, rendered antiseptic by boracic acid and other 
agents, is also found in the shops. 

Charpie. — This consists of a mass of loose short threads, 
made by separating pieces of linen or muslin measuring 
four or five inches square. It may be either fine or coarse, 
according to the character of the material employed. It 
can be arranged into a variety of forms, so as to be 
adapted to the various kinds of wounds ; these are called 
tents, pledgets, etc. 

Cotton. — In the raw state or arranged in sheets, as 
cotton batting, this material is used as a dressing. In 
this respect, its value has been increased recently by the 
introduction of various processes which are employed to 
render it antiseptic, and give to it absorbent properties. 
It can be made hygroscopic by boiling it in lye. Salicylic 
cotton is made by immersing the hygroscopic cotton in 
solutions of salicylic acid, alcohol, and water. Three per 
cent, salicylic cotton is made by immersing twelve pounds 
of hygroscopic cotton in a solution of six ounces of sali- 
cylic acid, one gallon of alcohol (sp. gr. 0.830), and nine 
gallons of water, at a temperature of 150 . 

Wool. — Finely carded wool has been employed as a 
dressing; it possesses no advantage over cotton, and is 
more expensive. 

Oakum. — This material is made by untwisting and 
separating pieces of old tarred rope ; it is subsequently 
cleaned, and forms an excellent dressing ; is cheap, readily 



SURGICAL DRESSINGS. 



*5 



obtainable, and possesses decided advantages by virtue of 
the tar it contains. 

Tenax or Tow. — A preparation of flax or hemp is also 
used as a dressing ; it is not as available as the oakum. 

Spongio-piline is made by felting together layers of lamb's 
wool and sponge, and coating one of the surfaces with 
rubber, which renders it impermeable to moisture. This 
is an elegant preparation, but too expensive for general 
use. 

Muslin and Linen. — Pieces of old muslin or linen are 
most frequently used as articles of dressing, and are quite 
as serviceable as the more costly materials. 

The various articles of dressings can be formed into 
different shapes, as the square, oblong, triangular, cribri- 
form, or graduated compress, the Maltese cross, etc. The 
formation of the square, oblong, and triangular compress 
is quite easy, the name indicating the form. 

The Cribriform Compress is made by folding a square 
piece of muslin four or five times 
on itself, and then nicking the 
border in a number of places 
with the scissors. When opened, 
it will present a cribriform ap- 
pearance. The openings which 
are made permit the free escape 
of discharges (Fig. i). 

The Maltese Cross derives its 
name from the shape, and is 
made by folding a square piece 

of the material from which it is to be formed into an ob- 
long square, folding this into a smaller square, then into 
a triangle so as to bring the free edges in contact, and 



Fig. i. 



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I J 

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* l M 


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t 1 « f 


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i S i 


lift 


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1 f j 


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llli 


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f M ) 


' 1 ' 


♦ Mi 


$ J. I 



16 



SURGICAL DRESSINGS. 



slitting the base of this triangle to two-thirds of its extent, 
the incision beginning at the end formed by the joining of 
the free edges (Fig. 2). On opening the piece it will be 
found that a regular Maltese cross has been formed (Fig. 3). 



Fig. 2 . 



Fig- 3- 





The Half Maltese Cross is formed by folding an oblong 
square into a smaller square, then into a triangle, and 
incising the base as above described (Fig. 4). 

These forms are useful in dressing stumps after amputa- 
tions. 



Fig. 4. 



Fig- 5- 





The Graduated Compress consists of a number of folds, 
so arranged that each succeeding fold covers about one- 
half of that preceding it (Fig. 5). 



SURGICAL DRESSINGS. 



17 



The Pyramidal Compress is prepared by sewing together 
square pieces which gradually de- 
crease in size, so placed as to form Fl S- 6 - 
a pyramid (Fig. 6). These are 
used for making pressure. 




It is frequently desirable to cover 
dressings with an impermeable 
covering, so as to retain moisture 
or prevent the escape of discharges 
upon the bedclothes or clothing. 

Among these articles are oiled silk, waxed paper, oiled 
paper, and gum tissue or rubber cloth. 

Oiled Silk is made by coating pieces of silk with layers 
of boiled oil, containing the oxide of lead to render it dry. 
This was formerly much employed; lately it has been sup- 
planted largely by less expensive articles. 

Waxed Paper. — This can be readily prepared by pass- 
ing sheets of strong tissue paper through melted white or 
yellow wax or paraffin, and then hanging them up to dry. 
It serves the same purpose as the oiled silk, is quite inex- 
pensive, and can be thrown away after being used. A few 
drops of linseed oil added to the melted wax will render 
the coating less brittle. 

Oiled Paper is made by brushing sheets of paper with 
boiled oil, which has been reboiled with oxide and ace- 
tate of lead, sulphate of zinc, and burnt umber. 

Gutta Percha or Gum Tissue is a light and elegant dress- 
ing, but too expensive for general use. 

Rubber Cloth. — This material, prepared in very thin 
sheets, may be employed as an impermeable covering. 



i8 



SURGICAL DRESSINGS. 



Plasters. — Adhesive Plaster (Emplastrum Resinse). This 
plaster is found already prepared in the shops, spread upon 
cotton, twill, or swans' down. Care should be taken to 
select that which has been recently made ; when old it 
becomes dry, cracks, and loses its attachment to the cloth 
upon which it has been spread. 

In cutting strips, the scissors should be applied with the 
blades ve?y slightly open, using the cutting edges of the 

points only, and dividing 
Fig- 7- the plaster lengthwise, 

and not crosswise. The 
division should be ef- 
fected by pushing the 
scissors along, and not 
by closing the blades, 
the piece being firmly 
held by an assistant (Fig. 
7). If cut crosswise, the 
cloth stretches, and thus 
interferes with proper ap- 
plication of the strips. 
The width and length of 
the strips will vary ac- 
cording to the wants of 
each case; as a rule, they 
should be three-quarters 
of an inch wide, and 
long enough to extend 
three inches beyond the 
edges of the wound. In 
applying them, they should be placed first in contact with 
the central and the most dependent part of the wound, in 




SURGICAL DRESSINGS. 19 

order to draw it up and afford support from below upward. 
Small triangular pieces may be cut out of the strips at the 
points of contact with the surface of the wound, so as to 
permit the discharges to escape. The strips may be made 
to adapt themselves smoothly and evenly to a round or 
irregular surface by nicking the edges. Before applying 
the strips of plaster, it is necessary that they should be 
heated, and the most efficient, and, at the same time, most 
convenient method is to place the cloth side of the strips 
in contact with the surface of a tin can or bottle contain- 
ing hot water : in this way the surface is equably heated 
and softened, so as to adhere to the skin. Attempts to 
heat adhesive strips over the gas-light, candle-light, spirit- 
lamp, over the surface of the stove, by dipping them in 
hot water, or by applying such an agent as chloroform, 
usually result in failures to secure that equable heating 
and softening of the adhesive surface which is so desirable 
in securing a firm attachment to the surface of the skin; 
besides, the strips are liable to be scorched and discolored, 
and thus detract from the neat appearance of the dressings. 

In order to remove the adhesive strips, warm water 
should be applied to the surface by means of a sponge or 
cloth. The ends should then be taken hold of, and the 
strip gently raised from each side of the wound to within 
an inch of the line of the incision (Fig. 8). The edges of 
the wound should now be supported by the thumb and 
index finger of one hand, while the strip is lifted in a 
vertical direction from the part. Sufficient space should 
always be left between the strips to permit free escape of 
the discharges. 

Besides the officinal adhesive plaster, other varieties are 



SURGICAL DRESSINGS. 



employed, such as Isinglass Plaster, Court Plaster, etc. 
These require to be moistened, and not heated, in order to 

Fig. 8. 




be made to adhere to the surface, and are more desirable 
applications in wounds of the face and head. 



Fie 



Poultices, or Cataplasms, are soft, moist substances 
which are employed in the treatment of wounds (Fig. 9). 
They are designated as the emol- 
lient, astringent, stimulating, 
fermenting, rubefacient, nar- 
cotic, etc. 

The Emollient Poultice is that 
form most commonly used, and 
may be made of bread and milk, 
corn meal and water, flaxseed 
meal, ground elm bark, or any 
unirritating substance. The flax- 
seed or linseed meal poultice is made thus: A quantity 
of recently ground meal is put into a basin which has 



rjj 




MM I 




IJiBBi 


i 








r^ 



SURGICAL DRESSINGS. 21 

been scalded, and boiling water is poured into it gradually, 
the mixture being well stirred, until it acquires a con- 
sistency which will prevent its running out when the basin 
is inverted. It is then to be spread with a spatula or table 
knife, to a thickness of one-quarter to three-quarters of an 
inch, upon a piece of strong muslin of the proper size, a 
border of an inch in width being left uncovered. The 
corners of the cloth are now incised with the scissors, and 
the borders folded over so as to form a margin, which will 
prevent the adhesion of the edges to the surface, and also 
the escape of the contents of the poultice. A piece of fine 
white gauze or mosquito netting (that which has been 
dyed should not be used) may be placed over the poultice 
to prevent it from adhering, and folded down with the 
edges of the cloth. A few drops of olive oil may be 
poured over the surface to soften it, or any article with 
which it is thought desirable to medicate the poultice, as 
tincture of opium, etc. 

In order to retain the moisture in the poultice, it should 
be covered with a piece of oiled silk, or with waxed paper. 

As a rule, poultices should be renewed twice in twenty- 
four hours, — more frequently if the conditions of the case 
demand it. 

The Astringent Poultice can be made by adding the 
astringent substance to the linseed meal or bread and milk 
poultice. 

The Stimulating Poultice may be made of various sub- 
stances, as grated boiled carrot, horseradish, garlic, black 
pepper, brine and corn meal, etc. 

The Fei'menting Poultice is usually made by mixing corn 
meal with yeast or porter. 

The Rubefacient Poultice is made by mixing flour of 



2 2 SURGICAL DRESSINGS. 

mustard with water until a proper consistency is obtained. 
Its strength may be reduced by the addition of flour, in 
the proportions of one-quarter or one-half. Vinegar should 
not be used in preparing these poultices, . as it destroys 
their rubefacient properties. 

A poultice of great value in the treatment of cases of 
hospital gangrene may be made of equal parts of pow- 
dered animal charcoal and brown sugar. 

Poultices may be confined to the part by a few turns of 
a roller or by broad strips of adhesive plaster. When 
applied to such a part as the breast, they should be cut in 
a circular form and the circumference nicked to the extent 
of an inch or more in order that they may adapt themselves 
to the surface. 

Methods of Irrigation. — It is frequently necessary, in 
the treatment of surgical affections, to apply water dress- 
ings, or heat or cold either in the dry or moist form. 
The simplest method in the moist form is to apply com- 
presses wrung out in warm or cold water ; this is incon- 
venient, however, and does not secure a uniform effect. 
A simple and efficient plan is to put a piece of lamp -wick 
or a number of threads into a reservoir of water placed some 
distance above the level of the patient's body, which, 
acting as a siphon, conveys the fluid uniformly over the 
part. 

Dry cold and dry heat may be conveniently applied in 
the form of the rubber bags or thin metallic boxes — con- 
taining in the one case ice, and in the other hot water. 
The most efficient method of applying dry cold or heat is 
by means of the rubber tubing as suggested by M. Petit- 
gand. A flexible rubber tube sixteen to twenty feet in 



SURGICAL DRESSINGS. 23 

length and one-half of an inch in diameter is applied 
around the part in a spiral manner and held in position by 
a few turns of a roller or by adhesive strips. The walls 
of the tube should be not more than a line in thickness, 
and the end which is placed in the reservoir should have 
a metallic cap heavy enough to sink it, and so arranged 
that the water can have free access to the tube. The other 
end should be provided with a ^stopcock and nozzle, so 
that the flow of the water through the tube can be regulated. 
The reservoir of water is placed above the level of the 
patient, as in the other forms. In all cases where water- 
dressings are employed, the bed should be protected by a 
rubber cloth or other suitable material. 

Sponges. — These play an important part in all surgical 
operations and in the dressing of wounds. They should 
be selected with great care, and none but those which are 
of fine and soft texture should be used. When obtained 
in the shops, it will be found that, as a rule, they contain 
particles of sand and sometimes other foreign substances. 
Before using, therefore, they should be thoroughly beaten, 
washed, and allowed to soak for a number of hours, if 
practicable. When the calcareous particles cannot be 
entirely removed by washing, they should be placed for a 
short time in a dilute solution of hydrochloric acid, one part 
to thirty of water, which will dissolve them. It is of great 
importance that they should be perfectly free from all 
foreign matter, and should be made scrupulously clean be- 
fore using. It is a good and safe rule to have new sponges 
for each patient, which will be used only for that person. 
When new sponges cannot be procured, those which have 
been used can be thoroughly cleansed by soaking them in 



24 SURGICAL DRESSINGS. 

a four per cent, solution of permanganate of potassium, 
then in a twenty-five per cent, solution of sulphurous acid, 
and finally washing thoroughly in water; or, they may be 
well washed in a solution of carbolic acid and kept con- 
stantly in this solution. Under no circumstances should 
sponges which have been employed in dressing erysipela- 
tous or. gangrenous wounds, or those of a contagious cha- 
racter, be used in dressing the wounds of another patient. 
If this precaution be neglected, the gravest consequences 
may ensue in the conveyance of infectious diseases. 

In dressing a wound the sponge should never be placed 
in contact with the granulating surfaces. The water should 
be allowed to flow upon the surfaces by compressing the 
sponge raised some distance above. About the edges of 
the wound and adjacent surfaces the sponge should be 
applied gently, so as to^ remove discharges. 

In using the sponges in operations they should be tho- 
roughly squeezed out so as to absorb readily the blood, and 
should be pressed upon the denuded surfaces and not 
rubbed. They should never be used for removing the 
blood from the floor after operations, or for any purpose 
other than that for which they were intended. 

INSTRUMENTS USED IN DRESSING WOUNDS. 

The instruments which are usually required in applying 
or removing dressings are few in number, and consist of a 
pair of Dressing Forceps, Dissecting Forceps, and Scissors. 

The Dressing Forceps are shaped like the ordinary scis- 
sors, terminating in rounded, spoon-shaped ends, the edges 
and inner surfaces of which are serrated. They are used 
to seize hold of dressings and remove them from the sur- 
face of wounds (Fig. 10). 



SURGICAL DRESSINGS. 
Fie. IO. 



25 




The Dissecting Forceps are employed to remove minute 
pieces of dressing, foreign bodies, etc., doing this more 
readily than the dressing forceps (Fig. 11). 



Fig. 11. 




The Scissors may be either straight or curved, and are 
used to give shape to the articles of dressings, etc. They 

Fig. 12. 




should not as a rule be used to divide the tissues, as they 
produce a contused edge in the wound which interferes 
with the union (Figs. 12, 13). 
3 



26 



SURGICAL DRESSINGS. 



These are found in the Pocket Case, with other instru- 
ments which are used in operations and in the treatment 
of disease (Fig. 14). 




As it is quite desirable to have the Pocket Case small in 
size and not too bulky, and yet contain all of the instru- 
ments required, some tact has been displayed in arranging 
them. That known as Professor S. D. Gross's case contains : 
One Scalpel and Straight Bistoury; two Curved Bistouries, 



SURGICAL DRESSINGS. 



2 7 



probe and sharp-pointed; one Tenotome and Tenaculum ; 
one pair Artery and Needle Forceps combined ; one pair 

F>g. 15- 




of Scissors; one pair of Polypus and Dressing Forceps; 
one pair Dissecting Forceps; one Exploring Needle; one 
male and female Catheter; one Porte- caustique ; one 

Fig. 16. 




Gross's Ear Instrument; one Grooved Director; one 
pair of Probes ; one half-dozen Needles, and one skein 
of Silk. The cutting instruments are double-bladed, with 
slide locks to secure the blades, either opened or closed 
(Figs. 15, 16). Dr. W. W. Keen has suggested a modifi- 



28 SURGICAL DRESSINGS. 

cation of the pocket case which materially reduces its size, 
and at the same time adds three instruments. As arranged 
by him it measures 4^ X 2^ X i}6 inches, and contains 
in addition a hypodermic needle, a thermometer, and a 
tubular needle. 

DRESSING A WOUND. 

In order to dress a wound the following articles and 
instruments should be at hand : Water, both hot and cold ; 
receptacle for the soiled dressings, basins, sponges, lint or 
other material to form compresses, syringes, rubber-cloth 
to protect the bed, towels, bandages, adhesive plaster, tin 
can containing hot water to heat the plaster, needles, pins, 
and pocket case containing dressing forceps, dissecting 
forceps, arid scissors. 

A sufficient number of assistants should always be pre- 
sent, in order that the dressings may be removed and 
applied with as little delay as possible. Usually three are 
required: one to support the part, one to attend to the 
sponges and supply of water at proper temperature, and a 
third to hand the dressings and instruments. Before ex- 
posing the wound, the assistants should be assigned to their 
respective positions, the dressings prepared, and everything 
in readiness. The rubber cloth should be placed so as to 
protect the bed, and the part lifted by the assistant and 
held in a comfortable and easy position. The soiled dress- 
ings should be removed carefully and placed in a covered 
receptacle and taken from the room. The wound should 
be cleansed by allowing the water to flow over it, squeezed 
out of a sponge held some distance above its margin, or 
vertically over it. If cavities exist, these can be thoroughly 
cleansed by throwing water into them with a syringe, being 



SURGICAL DRESSINGS. 



2 9 



careful to avoid giving too much force to the stream. The 
borders of the wound and adjacent surfaces should be 
gently wiped with the sponge, with regular and even mo- 
tions, carrying it toward the edges so as not to cause them 
to separate or to pull upon the sutures if they still remain. 
Short, jerking movements should be avoided in using the 
sponge, as they give pain and are liable to cause separation 
of the edges. of the wound. The sponge should not be 
placed in contact with the denuded surfaces. Collections 
of pus can be removed by a gentle stream of water thrown 
by the syringe, and foreign bodies can be picked off 
readily by the dissecting forceps. 

When cleansed, the borders should be dried by pressing 
a clean, soft towel upon them, care being taken to avoid 
bringing it in contact with the wound. If required, the 
adhesive strips already cut should be applied in the manner 
directed above (page 19). The compress, upon which has 
been spread the cerate or substance employed, is placed 
over the wound, and held in position by turns of the roller 
or broad adhesive strips. 

The more important points in applying dressings, to which 
the attention of the student is directed, may be expressed 
in a few general rules: — 

I. The position of the patient should be that which is 
most comfortable and free from restraint. The bed or 
table should be placed so as to afford ample light and space 
to those engaged in the dressing. 

II. Every article required in the dressing should be 
prepared and arranged before the wound is exposed. 
They should be placed in order, so that they can be easily 
and quickly reached. 

III. The removal of the old dressings, the cleansing of 

3* 



30 SURGICAL DRESSINGS. 

the wound, and the application of the new dressings should 
all be performed in such manner as to avoid giving unne- 
cessary pain to the patient. Every movement of the sur- 
geon and assistants should be- made with care — rough 
handling of the patient or of the wound should not, under 
any circumstances, be permitted. If the removal and 
application of the dressings cause great pain, the patient 
should be placed under the influence of an anaesthetic agent. 

IV. The wound should be exposed for as short a time 
as possible. Renewal of the dressings, unless the discharge 
is excessive, is not usually required oftener than once in 
twenty-four hours. Frequent dressings disturb and expose 
the wound, and thus interfere with the process of repair. 

V. The fingers should not be used in removing the 
dressings or foreign substances from the wound, lest dis- 
ease should be thus conveyed from one to another patient, 
or the surgeon become infected by the discharges. 

VI. The hands of the surgeon and assistants should be 
carefully washed both before and after the dressing. 

VII. All of the instruments used should be kept scru- 
pulously clean. 

THE ANTISEPTIC SYSTEM OF DRESSING WOUNDS. 

This is a system introduced by Professor Joseph Lister, 
formerly of Edinburgh, but now residing in London, who 
defines it as " the dealing with surgical cases in such a way 
as to prevent the introduction of putrefactive influences 
into wounds." 

The following articles are necessary in order to properly 
carry out the antiseptic method in surgical operations and 
dressings : — 



SURGICAL DRESSINGS. 



3 1 



i. Three solutions of carbolic acid, i to 40 (twelve grains 
to the ounce), 1 to 30 (sixteen grains to the ounce), and 
1 to 20 (twenty- four grains to the ounce), should be pre- 
pared, — the first for the protective and loose layer of 
gauze, the second for the spray, and the third in which 
the sponges, instruments, and drainage tubes are immersed, 
and also which is used to wash the part and the hands of the 
surgeon and. assistants. 

2. Steam Spray Apparatus. — This consists essentially of 
a spirit lamp with a hollow wick, a boiler to contain water, 
and a spray-tube. An excellent and inexpensive apparatus 









Fig. 17. 







has been devised by Dr. R. F. Weir, of New York (Fig. 
17). In the majority of cases the ordinary steam atomizer 
can be used with equal facility. 

3. Antiseptic Gauze. — This is prepared as follows: — 
Coarse- meshed cotton cloth, known as dairy or cheese 
cloth, is heated above 212 , and then sprinkled with its 



32 SURGICAL DRESSINGS. 

own weight of a mixture of carbolic acid one part, common 
resin five parts, and paraffin seven parts, the latter being 
melted together in a water-bath, and the acid then added 
by stirring. Pressure is then applied, so as to disseminate 
the liquid equally through the cloth. Old mosquito net- 
ting, which has been boiled in lye, can be used in place of 
the dairy cloth. The gauze is applied over the wound in 
eight layers. Its purpose is to absorb the fluids from the 
wound, and to prevent their decomposition. 

4. The Mackintosh. — This is a material used in the 
manufacture of hats, and consists of thin cotton cloth with 
a layer of red vulcanized rubber on one side. Thin rub- 
ber cloth, oiled silk, or gutta percha tissue will be found 
probably as effective. The material used should be free 
from holes. The Mackintosh is used to compel the secre- 
tions to permeate the whole dressing, thus being constantly 
in contact with the carbolic acid. It is placed between 
the seventh and eighth layers of the gauze. 

5. Rubber Tubings. — These are used for drainage, and 
vary in size from one-eighth to one-half of an inch. 
Numerous openings, each half the diameter of the tube, 
are made on the side. 

6. The Protective is a piece of oiled silk which is placed 
over the wound to protect it from the irritating effects of 
the carbolic acid in the antiseptic gauze. It is prepared 
by coating it with a thin layer of copal varnish, and then 
brushing over with a mixture of dextrine one part, starch 
two parts, and sixteen parts of the one-to-twenty carbolic 
acid solution. 

7. Carbolized Catgut Ligatures are made by putting cat- 
gut ligatures into a mixture of carbolic acid one part, dis- 



SURGICAL DRESSINGS. 33 

solved in one-tenth its weight of water, and then added to 
five parts of olive oil. 

8. Carbolized Silk Sutures are prepared by placing them 
in a mixture of melted wax ten parts and carbolic acid 
one part, and afterward drawing them through a folded 
cloth to render them smooth. 

9. Sponges. — -These are carefully beaten, cleaned, and 
washed in lukewarm water, and kept in the one-to-twenty 
solution of carbolic acid. After use they are cleaned 
and returned to the solution. 

An operation under the system is performed as follows : 
Three shallow basins (those which are oblong in shape 
are more convenient) should be at hand ; one to hold the 
instruments and one the sponges, each containing the one- 
to-twenty-solution. The hands, and particularly the finger 
ends, of the surgeon and all of the assistants are to be 
washed in the other basin, containing a solution of the 
same strength. The bottle of the spray apparatus is filled 
with the one-to-thirty solution, and the apparatus set in 
operation. The surface is washed with the one-to-twenty 
solution, and the spray directed upon the part. The inci- 
sion is made, the blood cleared away by the sponges, 
vessels ligated with the catgut ligatures, which are cut off 
short ; drainage tubes introduced into the depths of the 
wound and brought out to the surface at the most de- 
pendent part and cut off short, and the wound closed 
with the carbolized silk sutures. If complete drainage 
cannot be effected through the wound, a counter opening 
should be made, and the drainage tube introduced through 
it. A piece of the oiled silk protective, of a size to barely 
cover the edges, is now placed over the wound, then a 
piece of the gauze, of such size as to largely overlap the 



34 SURGICAL DRESSINGS. 

wound, in eight layers, with a piece of mackintosh between 
the seventh and eighth, and over all a bandage. The 
protective and six layers of the gauze, with the piece of 
mackintosh, should be kept in the one-to-forty solution, 
so as to be wet when applied ; the two remaining layers of 
the gauze are applied dry. If, during the operation, the 
spray apparatus fails, the piece of gauze must be quickly 
applied over the wound, and kept there until the spray is 
again directed upon the part. The dressing is, as a rule, 
renewed in twenty-four hours, and this is done under the 
spray, the same precautions being taken as in the first 
dressing. If the piece of oiled silk protective is unchanged 
in color, the wound is aseptic. If it shows dark brownish 
spots, which are caused by the action of the liberated sul- 
phur in the pus upon the lead in the oiled silk, the wound 
is septic, and should be washed out with the one-to-twenty 
solution, or with a solution of chloride of zinc, one part of 
the solution of the chloride of zinc to three parts of water. 

In redressirg, everything is renewed except the mack- 
intosh, which can be washed off with the one to-twenty 
solution and reapplied. The extent of the discharge, the 
sensations of the patient, and the temperature elevation, 
are the guides which direct with regard to a renewal of the 
dressings. If the dressing has been successfully applied, 
the temperature should be normal or but little elevated. 
So long as everything is favorable the dressings need not 
be disturbed : in cases of compound fractures they may 
be allowed to remain in place for weeks. 

In cases of wounds not made by operation, as lacerated 
wounds, compound fractures, etc., a somewhat different 
plan of treatment is to be adopted, although the articles 
of dressing and their method of application are the same. 



SURGICAL DRESSINGS. 



35 



The wound is to be treated as a septic wound, and is to be 
thoroughly washed out with a one-to-twenty carbolized 
solution, or a solution of one part of carbolic acid to five 
parts of spirits of wine, and then dressed as before described. 
In cases of suppurating wounds, old ulcers, etc., they should 
be first swabbed out with a solution of chloride of zinc, 
forty grains to the ounce, and then dressed with the usual 
antiseptic dressings. 

While it is hoped that pus will not form under the anti- 
septic method of dressings, yet it is not claimed that it will 
not occur. In such cases the " antiseptic suppuration," as 
it is called, is said to be "due to the direct chemical stim- 
ulus of the antiseptic." 



Splints. — Splints are appliances used in the treatment 
of fractures. They can be made of wood, leather, tin, 
felt, binders' board, or other material, and fashioned so 
as to fit the part. Before applying, they should always be 
carefully padded by covering them with layers of cotton 
batting, and holding this in place by spiral turns of a roller. 



1WRT II. 

BANDAGING 



lUNn.unNG is the art of applying bandages. Bandages 
mo substances which arc employed in the treatment o( 
surgical affections, and consist o( the simple and the com' 
pound bandages. They may be made from various mate- 
rials, such as muslin, tlanncl. etc. For general use the 
material best adapted is unbleached muslin ; that which is 
firm, smooth, soft, and closely woven should be selected. 



THE SIMPLE BANDAGE OR ROLLER, 

This may be from one to tour inches in width, and from 
six to twelve yards in length. The ordinary roller used 
in practice is six to eight yards long, and two to two and 
a half inches wide. In preparing the roller a piece of 
muslin, six to twelve yards in length and one yard in 
width, should be soaked in water for some time in order 
to cause shrinkage, then dried, and smoothly ironed. The 
selvage is removed, the free edge divided by the scissors 
at the points marking the widths o\ the bandages, and the 
strips torn rapidly, so as to avoid too much unravelling. 

In order to apply the bandage it should be formed into 
rollers or cylinders; tins can be done by a machine (Fig. 
l8) Or by the hand. It is quite desirable that the student 

( 3* ) 



BANDAGING. 



37 



should learn to roll the bandage firmly by the hand, as 
the machine is not always convenient, and besides, con- 
Fig. 1 8. 




stant handling of the bandage gives him better knowledge 
and control of it. The strips can be conveniently made 
into rollers in the following manner: Having arranged a 
strip in regular folds, a graduated compress is formed at 
one extremity and turned over firmly upon the thigh and 
rolled a few times until a cylinder is formed of such size 
as to be readily grasped by the hand ; then it is placed 
between the thumb and index and middle fingers of the 
left hand, the body of the bandage being held by the 
thumb and extended index finger of the right hand, while 
the remaining fingers grasp the cylinder. The cylinder 
thus held is made to revolve upon its axis by the left 
4 



3« 



BANDAGING. 



Fig. 19- hand, while the right revolves 

partially around the roller it- 
self, these movements soon 
completing its formation. In 
forming the roller in this man- 
ner, the cylinder may be held 
in either the right or left hand, 
as is most convenient (Fig. 19). 
The roller should be firmly and 
compactly formed, so trjat the 
central portion or axis cannot 
be pushed out readily. Prac- 
tice will enable the student to accomplish the formation 
rapidly and firmly. After forming the roller it should 
be firmly grasped and all loose threads removed, as these 
interfere with its proper application. 

Rollers are of two kinds, Single-headed and Double- 




headed. 



The single -headed 



Fig. 20. 




Fig. 21. 



roller consists of a body or 
central part, an initial and a 
terminal end, and an external 
and internal surface (Fig. 20). 
The double-headed roller has 
the same parts as the single- 
headed, both ends being form- 
ed into rollers (Fig. 21). The 
dimensions of the roller for the 
different parts of the body vary. 
For the Head — Five yards long and two inches wide.' 
For the Body — Twelve yards long and four inches wide. 
For the Extremities — Eight yards long and two to 
three inches wide. 




1 



BANDAGING. 



39 



For the Hand — From 
five to eight yards long 
and one inch wide. 

The application of the 
roller should begin by 
placing the external sur- 
face of the initial end in 
contact with the part, se- 
curing it in position by 
a circular turn, and the 
cylinder should be held 
firmly in the palm of the 
hand. When the applica- 




tion is completed, the ter- 
minal end should be fas- 
tened by folding in the 
edge and introducing a 
pin transversely or hori- 
zontally as may be most 
convenient, the head being 
directed upward or out- 




Gangrene from tight bandaging. 



40 BANDAGING. 

ward (Fig. 22), care being taken to cover the point. Pins 
should be introduced at the points where turns of a roller 
cross one another, so as to hold them in place. In apply- 
ing a bandage to an extremity, it should begin at the distal 
part, in order to make equable pressure upon the blood- 
vessels. 

If a wet bandage is to be applied, it should be soaked 
in the lotion before application, otherwise, undue contrac- 
tion will ensue if made wet when it is on the limb. 

The amount of traction to be used in the application of 
a bandage is a matter of the utmost importance, and should 
be very carefully considered by the student; practice alone 
will enable him to acquire a proper knowledge upon this 
point. A bandage too tightly applied may do great harm, 
even to the production of gangrene (Fig. 23), the loss of 
a limb, and possibly the loss of life. The sensations of 
the patient and the condition of the circulation in the limb, 
as shown at the distal points, are the best guides. These 
should be carefully noted a short time after the application 
of the bandage. If the patient complains of pain and 
numbness in the limb, and if the temperature of the part 
is lowered and the skin gives evidence of retarded circu- 
lation, then the bandage should be immediately removed. 
With regard to the tension the patient should always be 
consulted, and inspections at short intervals should be 
made. 

In applying the bandage to the head or trunk, the stu- 
dent should stand at the side of the patient, not in front 
of or behind, .and in making the various turns of the roller 
he should not walk around the patient but maintain a fixed 
position. In conveying the turns about the part, the 
bandage should be unrolled with an even and steady 
movement, not by short jerks. In removing the bandage 



BANDAGING. 



41 



from a part, each turn should be carefully taken off and 
folded in the hand. 

Bandages are designated as the Circular, Oblique, 
Spiral, Spiral-reverse, Figure-of-8, Spica, and Re- 
current, according to the direction they take in appli- 
cation. 

The Circular bandage consists of circular turns about 
the part. 

The Oblique bandage covers the part by very oblique 
turns. 

The Spiral bandage is applied by making spiral turns, 
each succeeding turn covering one-half of the preceding. 

Fig. 24. 




The reverse turn in this bandage is made in order that 
the bandage may adapt itself equably and with more 
firmness to the part. In making it, the limb should be 
grasped by the left hand, so as to retain the preceding 
turn by the thumb and fingers ; the roller, with not more 



42 BANDAGING. 

than three inches unrolled, should be held above the part, 
the hand being in a state of supination. The unrolled 
portion of the bandage being kept perfectly lax, the right 
hand, holding the roller, should be turned from supina- 
tion into pronation (Fig. 24), making in this movement a 
short turn, and passing the roller under the limb into the 
left hand. The position of the roller in the hand should not 
be changed, nor should traction be made until the limb is 
passed. 

The reverse turns will be in a line, if care is taken to 
keep the spaces between the successive turns of the bandage 
equidistant ; they should not be made over a joint or a 
subcutaneous bone, owing to the increased pressure they 
exert. 

In the Figure-of-8 bandage the turns cross each other so 
as to resemble the figure after which it is named. 

The Spica bandage is so named from its resemblance 
to the arrangement of the leaves of an ear of corn. 

The Recurrent Bandage. — In this the turns return suc- 
cessively to the point of origin, so as to form a covering 
for a part. 

The simple bandage consists of the Roller, either single 
or double headed, and is applied to various parts of the 
body. 

BANDAGES OF THE HEAD. 

Length of roller five yards, width two inches. 

1. Circular bandage of the forehead. 

2. Circular bandage of the eyes. 

3. Crossed bandage of one or both eyes. 

4. Crossed bandage of the angle of the jaw. 



BANDAGING. 43 

5. Knotted bandage of the head. 

6. Recurrent bandage of the head, with single or 
double-headed roller. 

7. Gibson's bandage for the body of the lower jaw. 

8. Rhea Barton's bandage for the body of the lower jaw. 

1. Circular Bandage of the Forehead. 

Origin — Side of the head. 

Course — Three or four turns encircling the vault of the 
cranium. 

Termination — Side of the head opposite to the point of 
origin. 

Use — To make pressure or retain dressings to the head. 

2. Circular Bandage of the Eyes. 

Origin — Temporal region. 

Course — Three or four turns over the eyes and around 
the head. 

Termination — Temporal region, opposite to the point 
of origin. 
. Use — To retain dressings to the eyes. 

3. Crossed Bandage of the Eyes. 

Origin — Side of the head. 

Course — Two circular turns around the head, in a direc- 
tion from right to left to cover the right eye, from left to 
right to cover the left eye, thence to the nape of the neck, 
adapting the bandage to the surface by a reverse turn, if 
necessary, under the ear, over the eye, across the root of 
the nose to the side of the head, on a level with the 
parietal eminence, then circular turn around the head, 
making two or three turns in this manner alternately, and 
covering two-thirds of each preceding turn. 



44 



BANDAGING. 



Termination — Circular turn around the head. 

Use — To retain dressings to the eye (Fig. 25). 

To cover in both eyes, after the first turn over the eye 
has been made, the bandage should pass around the head 
and then down across the forehead, the root of the nose, 
over the other eye, under the ear, to the occiput and side 




Fiji. 26. 




of the head, thence around the head to the nape of the 
neck, and pass in the same direction as in the first turn. 
Applying these turns alternately, both eyes will be covered. 
Use — To retain dressings to both eyes (Fig. 26). 

4. Crossed Bandage of the Angle of the Jaw. Roller 
and compress. 

Origin — Side of the head. 

Course — Two circular turns around the head, in a direc- 
tion from right to left to cover left angle, and left to right 
to cover right angle, to the nape of the neck, making a 
reverse turn, if necessary, behind the ear, under the jaw, 



BANDAGING. 45 

over the angle of the jaw, up in front of the ear, over the 
vertex obliquely, down behind the ear of the side opposite, 
under the jaw and repeat the turns three times, advancing 
from the angle of the jaw to the corner of the mouth. 

^Termination — By a reverse turn on the side of the head 
opposite to the injured side, and making two circular turns 
from before backward around the head. 

Use — To support parts in the treatment of fracture of the 
angle of the jaw. 

5. Knotted Bandage of the Head. Double-headed 
roller and compress. 

Origin — Body of the bandage over the compress cover- 
ing the wound in the artery. 

Course — Carry both heads of the roller around the 
head in opposite directions, passing at the temporal region 
of the opposite side and returning to point of origin. 
Change the direction by making a half turn or twist over 
the compress, carrying the heads of the roller in opposite 
directions over the vertex and under the chin to the temple 
of the opposite side, passing and returning to point of 
origin, where a second turn or twist should be made and 
the heads of the roller conducted as in first turn, placing 
the knots behind each other in order. Continue these 
turns until three or four knots are formed. 

Termination — Circular turns around the head, covering 
the knots. 

Use — To make compression in wound of the temporal 
artery (Fig. 27). 

Note. — This bandage, being applied with great firm- 
ness, makes great pressure upon the parts, and should be 
watched carefully in order to prevent injury. 



4 6 



BANDAGING. 



6. Recurrent Bandage of the Head. Single-headed 
roller. 

Origin—^ Side of the head. 

Course — Two circular turns around the head to the 
middle of the forehead, then reversing the bandage and 

Fig. 27. 





carrying it from before backward to the middle of the 
occiput, making a reverse turn and returning to the fore- 
head, covering one-half of the preceding turn and con- 
tinuing recurrent turns on alternate sides, covering one- 
half of each preceding turn, until the vertex is covered. 

Termination — By a reverse turn and then circular turns 
around the head to secure recurrent turns (Fig. 28). 

Recurrent Bandage of the Head. Double-headed 
roller. 

Origin — Body of the bandage over the middle of the 
forehead. 



BANDAGING. 



47 



Course — The heads of the roller are to be carried in 
opposite directions around the vertex to the occiput, pass- 
ing and returning to the point of origin; the recurrent 
turns are to be made by the head of the roller held in the 
right hand, each turn being secured by circular turns made 




by the head of the roller held in the left hand (Fig. 29) ; 
continue these turns until the vertex is covered. 

Termination — Circular turn around the head. 

Use — Both bandages are used to retain dressings to the 
head. 

7. Gibson'sBandagefortheBodyof the Lower Jaw. 

Origin — Temporal region. 

Course— Down in front of the ear, under the chin, up 
in front of the ear of opposite side, over the middle of the 
vertex to the point of origin, making two turns; then re- 



48 



BANDAGING. 



verse the bandage from before backward, making two 
circular turns around the head to the point of origin ; 
thence to the nape of the neck, making reverse turn if 
necessary, carrying under the ear, in front of the chin, 
and back to nape of the neck. Repeat this turn, make a 
reverse turn and go to side of the head, and around the 
head by two turns to the middle of the occiput ; make a 
reverse turn and carry bandage over the vertex to fore- 
head (Fig. 30). 

Termination — Either by circular turns around the head 
or by turn from occiput to forehead. 

Use — To support parts in treatment of fracture of the 
body of the lower jaw. 



Fig. 30. 



Fig. 31. 





8. Rhea Barton's Bandage. 

Origin — Beneath the occipital protuberance. 

Course — Obliquely upward over the parietal eminence, 
across the junction of the sagittal and coronal sutures, 
down in front of the ear, under the chin, up in front of 



BANDAGING. 



49 



the ear of the opposite side, across the junction of the 
sagittal and coronal sutures, over the parietal eminence to 
the point of origin ; thence obliquely downward and for- 
ward over the angle of the jaw, in front of the chin, over 
the angle of the jaw of the opposite side, obliquely upward 
and backward to the point of origin. Continue these turns 
until the bandage is exhausted (Fig. 31). 

Termination — Occipital region. 

Use — To support the parts in treatment of fracture of 
the body of the lower jaw. 



BANDAGES OF THE TRUNK. 

r. Circular bandage of the neck. 

2. Figure-of-8 bandage of the neck and axilla. 

3. Anterior figure-of-8 bandage of the chest. 

4. Posterior figure-of-8 bandage of the chest. 

5. Crossed bandage of one or both breasts. 

6. Spica bandage of the shoulder. 

7. Spiral bandage of the chest. 

8. Circular bandage of the abdomen. 

9. Spiral bandage of the abdomen. 

10. Spica bandage of one or both groins. 

1. Circular Bandage of the Neck. Length of roller, 
two yards; width, two inches. 

Origin — Side of the neck. 

Course — Three or four circular turns around the neck. 

Termination — Side of the neck. 

Use — To retain dressings to the neck. 

2. Figure-of-8 Bandage of the Neck and Axilla. 

Length of roller, five yards; width, two inches. 
Origin — Side of the neck. 
5 



5o 



BANDAGING. 



Course — Two circular turns around the neck; thence 
over the point of the shoulder, backward and downward 
to the axilla, under the axilla, up in front over the shoul- 
der to the point of origin, repeating these turns, two or 
three times. 

Ter?ni?tation — Circular turn around the neck. 

Use — To retain dressings over the shoulder or in the 
axilla. 

3. Anterior Figure-of-8 Bandage of the Chest. 

Length of roller, seven yards; width, two and one-half 
inches. 

Origin — Axilla of either side. 

Course — Two circular turns around the chest to the point 
of origin, thence obliquely upward across the chest to the 
point of the shoulder, over the shoulder backward and 

Fig. 32. 




downward to the border of the axilla, under the axilla 
obliquely upward, across the chest to the opposite shoul- 



BANDAGING. 



5* 



der, over the shoulder, backward and downward to the 
border of the axilla, under the axilla, repeating these turns 
three or four times (Fig. 32). 

Termination— -By circular turns around the chest. 

Use — To draw the shoulder forward, and to retain dress- 
ings on the anterior surface of the chest. 

4. Posterior Figure-of-8 Bandage of the Chest. 

This bandage is applied in the same manner as that just 
described, the turns being carried over the posterior instead 
of the anterior surface of the chest (Fig. 33). 

Fig- 33- 




Use — To draw the shoulders back in the treatment of 
fracture of the clavicle, or to retain dressings on the pos- 
terior surface of the chest. 

5. Crossed Bandage of one or both Breasts. 

Length of roller, eight yards ; width, two and one-half 
inches. 

Origin — Axilla of the affected side. 



52 



BANDAGING. 



Course — Two circular turns under the breasts, around 
the chest to the point of origin, thence obliquely upward 
under the affected breast, across the front of the chest to 
the shoulder, over the shoulder, obliquely downward across 
the back of the chest to the point of origin ; then by a 
circular turn, under the breast, around the chest to the 



Fig. 34- 




point of origin; continue these turns alternately, gradually 
advancing forward in the oblique turns, and upward in 
the circular turns until the breast is fully supported (Fig. 

34). 

Termination — Circular turns around the chest. 

Bandage for both Breasts. Length of roller, twelve 
yards ; width, two and one-half inches. 

This bandage is applied in the same manner as that just 
described, with the addition of oblique turns, supporting 
the other breast, which begin when the bandage, in the 



BANDAGING. 



53 



second circular turn, the first oblique turn having been 
made, has reached the opposite axilla; then pass across 
the back of the chest over the shoulder down obliquely 
across the front of the chest under the breast to the point 
of origin. These turns are continued, the circular and 
oblique turns alternating, until both breasts are supported 
(F'g- 35)- 

Fig- 35- 




Use — These bandages are used to support the breasts in 
excessive lactation, or in abscess. 

6. Spica Bandage of the Shoulder. Length of 
roller, eight yards; width, two and one-half inches. 

Origin — Arm of the injured side. 

Course — Circular and spiral-reverse turns to the point 
of the shoulder, over the shoulder, obliquely downward 
across the front of the chest, for the right shoulder, and 
the back of the chest for the left shoulder, to the axilla of 

5* 



54 



BANDAGING. 



the sound side, under the axilla, obliquely upward across 
the front or back of the chest to the point of the shoulder, 
down in front or behind to the border of the axilla, under 
the axilla to the point of the shoulder, covering one-half 
of the preceding turn, thence to the axilla of the sound 
side. Continue these turns, covering one -half of each 
preceding turn, until the shoulder is covered (Fig. 36). 




Termination — Circular turns around the chest. 
Use — To retain the head of the humerus in place after 
dislocation has been reduced. 

7. Spiral Bandage of the Chest. Length of the 
roller, ten yards; width, three to four inches. 

Origin — Circular turns around the waist. 

Course — By spiral turns around the chest, ascending to 
the axilla, covering one-half of each preceding turn. 

Termination — Circular turns around the upper part of 
the chest. 

Use — To make compression in fracture of the sternum 
or ribs, and to retain dressings. 



BANDAGING. 



55 



8. Circular Bandage of the Abdomen. Length of 
the bandage, from one and a half to two yards; width, 
from ten to twelve inches. 

Origin — Over the crest of the ilium. 
Course — Circular turn around the abdomen. 
Termination — Over the crest of the ilium. 
Use — To support the abdominal walls. 

9. Spiral Bandage of the Abdomen. Length of the 
roller, ten to twelve yards; width, three to four inches. 

Origin — Around the waist, or over the crest of- the 
ilium. 

Course — Spiral turns from above downward, or from 
below upward. 

Fig. 37- 




56 BANDAGING; 

Termination — By circular turns around the pelvis or 
around the waist, according to the course taken. - 

Use — To make compression of the abdomen. 

10. Spica Bandage of one or both Groins. Length 
of roller, eight to ten yards ; width, two and a half to 
three inches. 

Origin — Above the crest of the right ilium. 

Course — Two circular turns around the body above the 
crests of the ilia, thence obliquely downward across the 
groin to the inside of the right thigh to cover the right 
groin, to the outside of the left thigh to cover the left groin, 
around the thigh, across the groin obliquely upward to 
above the crest of the left ilium, and then to point of ori- 
gin ; repeat these turns, and cover one-half of each pre- 
ceding turn, until the groin is covered (Fig. 37). 

Termination — Circular turns above the crest of the ilia. 

Use — To make compression over the groin, as in case 
of bubo, or to retain dressings. To cover both groins, 
the turns, as described above, should be made to alternate 
(Fig. 38). 

BANDAGES OF THE EXTREMITIES. 

SUPERIOR EXTREMITY. 

Bandages of the Hand. 

1. Spiral bandage of the finger. 

2. Spiral bandage of all of the ringers, or the gauntlet. 

3. Spiral bandage of the palm, or demi- gauntlet. 

4. Spica of the thumb. 

1. Spiral Bandage of the Finger. Length of roller, 
one yard ; width, one inch. 



BANDAGING. 

Fig. 38. 



57 




Origin — Circular turns around the wrist. 

Course — From the wrist across the back of the hand to 
the base of the finger, thence by very oblique turns to the 
point of the finger, returning to the base by spiral or spiral- 
reverse turns, and thence to wrist (Fig. 39). 

Fig- 39- 







58 



BANDAGING. 



Termination — Circular turns around the wrist. 

Use — To retain dressings or to support parts in fracture. 

2. Spiral Bandage of all of the Fingers, or the 
Gauntlet. Length of roller^ eight yards; width, one 
inch. 

Origin — Around the wrist. 

Course — By turns, taking the same direction as those in 
the preceding bandage, each finger being covered sepa- 
rately, and the palm covered by spiral turns ascending to 
the wrist (Fig. 40). 



Fig. 40. 




Termination — Circular turns around the wrist. 
Use — To cover all of the fingers. 

3. Spiral Bandage of the Palm, or Demi-Gauntlet. 

Length of roller, six yards; width, one inch. 

Origin — Around the wrist. 

Course — By circular turns around the wrist, thence 
downward across the back of the hand to the first inter- 
digital space around the base of the finger, across the 
back of the hand to the wrist. Repeat these turns around 



BANDAGING. 



59 



the base of each finger until the back of the hand is cov- 
ered. 

Termination — Circular turns around the wrist. 

Use — To retain dressings on the back of the hand. 

4. Spica Bandage of the Thumb. Length of roller, 
three yards; width, one inch. 

Origin — Around the wrist. 

Course — From the wrist across the base of the thumb 
to the phalangeal articulation, around the thumb, across 
the base of the thumb to the wrist, and continue these turns, 
covering one-half of each preceding turn, until the thumb 
is covered (Fig. 41). 

Fig. 41. 




Termination — Around the wrist. 

Use — To make pressure over the base of the thumb, or 
to confine dressings. 



Bandages of the Arm. 

1. Circular bandage of the wrist. 

2. Figure-of-8 bandage of the wrist. 

3. Figure-of-8 bandage of the elbow. 

4. Circular bandage of the arm. 

5. Oblique bandage of the arm. 

6. Spiral- reverse bandage of the arm. 



60 BANDAGING. 

i. Circular Bandage of the Wrist. This bandage 
consists of two or more circular turns around the wrist. 
The spiral-reverse bandage of the upper extremity may 
begin by these turns. 

2. Figure-of-8 Bandage of the Wrist. Length of 
roller, two yards; width, two inches. 

Origin — Around the wrist. 

Course — Two circular turns around the wrist, over the 
back of the hand, to the palm of the hand, across the palm, 
and over the back of the hand to the wrist; make three or 
four turns, covering one-half of each preceding turn. 

Termination— Around the wrist. 

Use — To make compression over the joint, or to confine 
dressings. 

3. Figure-of-8 Bandage of the Elbow. Length of 
roller, two yards; width, two inches. 

Origin — Around the upper part of the forearm. 

Course — Two circular turns around the upper part of the 
forearm, then obliquely upward across the front of the 
elbow to the lower part of the arm, making circular turns 
around the arm and returning obliquely downward across 
the front of the elbow to upper part of the forearm; then 
by ascending spiral turns covering the entire joint. 

Termination — Circular turn around the arm. 

Use — To make pressure over the elbow joint, or to retain 
dressings. 

4. Circular Bandage of the Forearm or Arm. The 

application of this bandage consists in making circular turns 
around any part of the forearm or arm. 

Use — To retain dressings or to compress the superficial 
veins in venesection. 



BANDAGING. 



61 



5. Oblique Bandage of the Forearm or Arm. 

Length of roller, two to three yards; width, two inches. 

Origin — Around the hand. 

Course — Two circular turns around the hand, thence by 
very oblique turns up the forearm and arm to the shoulder. 

Termination — Circular turns around the upper part of 
the arm. 

Use — To retain dressings. 

6. Spiral-Reverse Bandage of 
the Upper Extremity. Length of 
roller, eight yards; width, two inches. 

Origin — Around the wrist by two 
circular turns. 

Course — From the wrist obliquely 
downward across the back of the 
hand to the metacarpo-phalangeal 
articulation, circular turn around this 
articulation, thence obliquely upward 
across the back of the hand to the 
wrist; then figure-of-8 turn of the 
wrist, spiral turns over the wrist-joint, 
ascending the forearm by spiral- re- 



verse turns to the elbow, crossing the 
elbow-joint by figure-of-8 turns and 
ascending the arm to the shoulder by 
spiral-reverse turns (Fig. 42). 

Termination — Circular turns around 
the upper part of the arm. 

Use — To support the arm in the 
treatment of fractures, dislocations, 
etc. 

6 




J 



62 BANDAGING. 

This bandage may begin by circular turns around the 
hand, over the metacarpophalangeal articulations, and 
then pass to the wrist by figure-of 8 turns. In passing over 
the wrist and elbow-joints, simple spiral turns should be 
made ; reverse turns increase the pressure and may do harm. 

BANDAGES OF THE INFERIOR EXTREMITY. 
i. Figure-of-8 bandage of the ankle. 

2. Figure-of-8 bandage of the knee. 

3. Figure-of-8 bandage of the thighs. 

4. Spica bandage of the instep. 

5. Spiral-reverse bandage of the lower extremity cover- 
ing the heel. 

6. French spiral bandage. 

1. Figure-of-8 Bandage of the Ankle. Length of 
roller, two yards ; width, two inches. 

Origin — Around the leg, above the malleoli. 

Course — Two circular turns around the leg above the 
malleoli, thence obliquely downward in front of the ankle 
to the side of the foot, under the sole of the foot to the 
opposite side, obliquely upward in front of the ankle to the 
point of origin, making as many turns as may be required. 

Termination — Circular turns above the malleoli. 

Use — To cover in the ankle or to retain dressings. 

2. Figure-of-8 Bandage of the Knee. Length of 
roller, two yards; width, two and one-half inches. 

Origin — Side of the upper part of the leg. 

Course — Two circular turns around the upper part of the 
leg, thence from side of the leg obliquely upward across the 
front or back of the knee to the side of the lower part of 
the thigh, circular turn around the thigh, then from oppo- 



BANDAGING. 



63 



site side of the thigh obliquely downward across the front 
or back of the knee to side of the leg, making the required 
number of figure-of-8 turns, and covering the joint by 
ascending spiral turns. 

Termination — Circular turns above the knee. 

Use — To cover in the knee or to make compression. 

3. Figure-of-8 Bandage of the Thighs. Length of 
roller, five to six yards; width, two and one-half to three 
Inches. 

Origin — Above the knees. 

Course — Beginning by circular turns above the knees, 
and making as many figure-of-8 turns as may be required 
to secure the limbs firmly together. 

Termination — Circular turns around the upper part of 
the thighs. 

Use — To fasten the thighs together after operations or 
injuries. 



Fig. 43- 



4. Spica Bandage of the Instep. Length of roller, 
six to eight yards ; width, two inches. 

Origin — Around the metatarso-phalangeal articulation. 

Course — By two circular turns around the foot, ascend- 
ing by spiral-reverse turns to the 
instep, then obliquely downward 
to the point of the heel, the edge 
of the bandage projecting slightly 
below the border of the sole of 
the heel, around the heel, obliquely 
upward to the instep, downward 
to the side of the foot, under the 
foot to the opposite side of the foot 
and to the instep; continue these 




64 



BANDAGING. 



Fig- 44- 



figure-of-8 turns, covering one-half of each preceding turn 
until the instep is entirely covered (Fig. 43). 
Termination — Circular turn above the ankle. 
Use — To make firm compression over the instep or ankle, 
5. Spiral-reverse Bandage of the Lower Extremity 
covering the Heel. Length of 
roller, ten to twelve yards; width, 
two and one-half inches. 

Origin — Around the foot at the 
metatarsophalangeal articulation. 

Course — Two circular turns 
around the foot, ascending by 
spiral-reverse turns to high up on 
the instep, thence over the point 
of the heel back to the instep, 
under the sole of the heel, over 
the side of the heel, around the 
back of the heel, up to the instep, 
under the sole of the heel, over 
the opposite side of the heel, 
around the back of the heel up to 
the instep, then figure-of-8 turns 
of the ankle, spiral turns over the 
joint, spiral- reverse turns to the 
knee, figure-of-8 turn of the knee, 
spiral turns over the joint, and 
ascending the thigh to the hip by 
spiral-reverse turns (Fig. 44). 

Termination — Circular turns 
around the upper part of the 
thigh. 

Use — To support the limb after 
fracture, etc. 




BANDAGING. 



65 



This bandage may begin around the ankle and pass to 
the foot, covering it, and return by figure-of-8 turns to the 
ankle, and then ascend the limb. 

Reverse turns should not be made over the ankle or 
knee-joints, or over the crest of the tibia, owing to the 
increased pressure they exert. 

6. French Spiral Bandage. This bandage is applied 
in the same manner as the preceding, the covering of the 
heel being omitted, passing from the foot to the leg by 
figure-o-f 8 turns. 



GENERAL BANDAGES. 

Bandage of Scultetus. This bandage consists of a 
number of separate pieces varying in length, the first being 
sufficiently long to go 



once and a third around 
the upper part of the 
limb, each succeeding 
piece decreasing one 
inch. The pieces should 
be arranged so that each 
strip covers in one-third 
of the preceding. The 
limb is placed upon the 
strips arranged in order, 
and the application is 
commenced at the low- 
est part, crossing one 
strip over the other in 
an oblique direction 
(Fig- 45)- 

*6 



F ig- 45- 




66 



BANDAGING. 



Use — To support the limb in cases of compound frac- 
tures, etc., where it is advisable to avoid motion in remov- 
ing dressings. 

Recurrent Bandage for Amputations. Length of 
roller, four to six yards ; width, two to two and one-half 
inches. 

Origin — Three to six inches above the end of the stump. 

Course — Two circular turns around the limb to the cen- 
tre of the under 
surface, thence by 
recurrent turns over 
the extremity of the 
stump to the centre 
of the upper sur- 
face; continue 
these recurrent 
turns on alternate 
sides of the central 
turn, covering in 
one -half of each 
preceding turn, un- 
til the stump is cov- 
ered. Fix the re- 
current turns by 
spiral turns de- 
scending to the end 
of the stump (Figs. 
46, 47). 

Termination — 
Circular turn 
around the stump. 

Use — To support the flaps of the stump after amputation. 




Fig. 47- 



\ 




BANDAGING. 



6 7 



Fig. 48. 



Velpeau's Bandage. Position of the arm : hand of 
the injured side grasping the sound shoulder. Length of 
roller, ten to twelve yards; width, two and one-half inches. 

Origin — The axilla of the sound side. 

Course — Obliquely upward across the back of the chest 
to the seat of the fracture, over the compress, covering 
the seat of the fracture, down 
across the outside of the arm 
to wider the elbow, in front of 
the chest to the axilla of the 
sound side, thence by a cir- 
cular turn across the back over 
the outside of the point of the 
elbow to the axilla of the 
sound side. Continue the ob- 
lique and circular turns alter- 
nately, advancing over the 
arm and ascending from, the 
point of the elbow until the arm is firmly supported 
(Fig. 48). 

Termination — By circular turn around the chest. 

Use — To support the arm in the treatment of fracture of 
the clavicle, the neck, or acromion process of the scapula. 

In applying this bandage, a compress of soft material 
should be placed between the arm and the surface of the 
chest to prevent excoriation. 




Desault's Apparatus. This consists of three single- 
headed rollers, a triangular pad to place in the axilla, and 
a sling to support the hand. 

The pad should be of such length as to extend from the 
axilla to the point of the elbow, and measure in width at 



68 BANDAGING. 

the base from three to four inches. Length of rollers, 
eight yards; width, two and one-half inches. 

First Roller. Origin — Over the apex of the pad ; 
placed in the axilla of the injured side. 

Course — Two circular turns around the chest over the 
apex of the pad, thence by spiral turns upward to the 
axilla, covering the pad and securing it in place. 

Termination — By circular turns around the chest. 

This roller can be dispensed with to advantage, and the 
pad held in place by tapes attached to its base passing 
around the neck. The arm should now be flexed at a 
right angle, pressing slightly against the side of the chest. 

Second Roller. Origin — Axilla of the sound side. 

Course — Circular turn across the front of the chest, over 
the upper part of the arm of the injured side, across the 
back of the chest to the point of origin, then by spiral 
turns descending to below the point of the elbow. 

Termination — Circular turns around the body. 

Use — To throw the shoulder outward by pressing the 
elbow inward, using the pad as a fulcrum. 

Third Roller. Origin — Axilla of the sound side. 

Course — Obliquely upward across the front of the chest 
to the seat of the fracture, over the seat of the fracture, 
down back of the arm to the elbow, under the elbow, 
across in front of the chest to the point of origin ; thence 
obliquely upward across the back of the chest to the seat 
of the fracture, over the seat of the fracture, down in front 
of the arm, under the elbow, across the back of the chest 
to the point of origin (Fig. 49). 

Tenni?iation — Circular turns around the chest. 

Use — To carry the arm upward and backward. 

It will be observed that two triangles are formed in 



BANDAGING. 



6 9 



applying the third roller, the first having the base behind 
the arm, the sides across the front of the chest, and the 
apex in the axilla of the sound side; while the second 
has the base in front of the arm, the sides across the back 
of the chest, and the apex in the axilla of the sound side. 
Use of the Apparatus. — To support the arm and over- 
come its displacement in the treatment of fractures of the 
clavicle. 



Fig- 5°- 




THE COMPOUND BANDAGES. 

Under this name are included — 

1. The T bandages. 

2. The invaginated bandages. 

3. The sling bandages. 

- 4. The suspensory bandages. 

1. The T Bandages. These derive their name from 
their resemblance to the letter T, and consist of a hori- 
zontal portion, sufficiently long to surround the part to be 
covered, and a vertical piece half the length of the hori- 



7o 



BANDAGING. 



zontal, firmly attached to its middle (Fig. 50). The band- 
age thus formed can be applied to various parts of the 
body. It is most frequently employed in retaining dress- 
ings to the perineum, when the horizontal portion is fast- 
ened around the body and the vertical band passed between 
the thighs and then attached to the horizontal piece. The 
napkin worn by women during menstruation is a familiar 
example of this form of bandage. 



Fig- 51. 



Fig. 52. 





2. The Invaginated Bandage. This bandage is 
formed by making strips or tails at the free extremity and 
at the proper distance cutting slits in the body of the band- 
age through which these tails pass. It was formerly used 



Ih 



BANDAGING. 7 1 

for the purpose of approximating the edges of wounds, 
but is now largely, if not altogether, discarded. 

3. The Sling Bandages. These are made of pieces 
of muslin or other material of various lengths and widths, 
torn at each extremity into two or more tails, leaving a 
central portion or body (Fig. 51). They are quite useful 
in retaining dressings or supporting pails. In applying 
them, the central portion or body is placed upon the part, 
and the tails are carried in different directions about the 
part, and secured by pins or knots. The Four-Tailed or 
"Poor Man's" Bandage is used in the treatment of frac- 
ture of the body of the lower jaw (Fig. 52). 

4. The Suspensory Bandages. These are made in 
the shape of bags or sacs of various sizes, and are used for 
the purpose of retaining dressings or supporting parts. 
They may be made of such material as is deemed most 
desirable. 

MAYOR'S SYSTEM OF HANDKERCHIEF 
DRESSINGS. 
This system of provisional dressings was introduced by 
M. Mayor, of Switzerland, in 1838. It consists in the 
use of the simple handkerchief, folded into various shapes, 
so as to accomplish the purposes of the roller. The di- 
mensions of this handkerchief vary according to the part 
to which it is applied, and may be made of any material 
which happens to be at hand. The forms into which the 
handkerchief may be made are: The Square, The Tri- 
angle, The Cravat, and The Cord. 

The Oblong Square is made by folding the handker- 
chief once on itself. 






72 



BANDAGING. 



The Triangle is made by folding the square so that 
the angles which are opposite come in contact. 

Fig. 53- Fig 54- 




The Cravat is made by folding the handkerchief in 
the form of the ordinary cravat. 

The Cord is formed by twisting the cravat on itself. 

Fig. 55. Fig. 56. 





lUiL 



BANDAGING. 



73 



Fig. 57- 



The handkerchief in the form of the Square may be 
employed to retain dressings over the head. 

In the form of the Triangle it can be used for the pur- 
pose of retaining dressings over the head (Fig. 53), the 
trunk, the shoulder, the elbow, the hand, the hip, the 
knee, and the foot; also to support or retain dressings 
over the mammary gland (Fig. 54), to act as a sling for 
the arm (Fig. 55), or to cover the stump after amputation 
(Fig. 56). In applying the handkerchief in the form of 
the Triangle, the base is to be applied to the part, and the 
angles carried about it and fastened by a knot. 

The Cravat may be used to 
retain dressings, to make pres- 
sure, or to support parts, as 
the arm (Fig. 57) The body 
should be applied over the 
part, and the ends carried 
once or twice around the part 
and fastened by a knot. The 
handkerchief in the shape of 
the cravat may be used to 
fasten the foot to the end of 
the fracture-box in cases of 
fracture of the leg. It should 
be applied by a figure-of-8 
turn, the body being placed 
over the tendo Achillis, and 

the ends carried across the instep and passed through the 
openings made in the end of the box, and then fastened 
by a knot. 

The Cord is used where it is necessary to make firm 
7 




74 



BANDAGING. 



pressure, as when it is applied over a compress in cases of 
hemorrhage. It may also be used in the form of the clove 
hitch for the purpose of making traction. The clove hitch 

Fig. 58. 





BANDAGING. 75 

is made by holding one end of the cord with the left hand 
and forming from the body a simple loop with the right 
(Fig. 58); holding this between the thumb and finger of 
the left hand, a second loop is made from the remaining 
portion of the body of the cord and held by the thumb 
and finger of the right hand ; passing the second loop be- 
neath the first, the hitch is formed (Fig. 59). 

IMMOVABLE BANDAGES. 

The Starch Bandage, the Plaster of Paris Band- 
age, and the Silica Bandage. 

1. The Starch Bandage. In this form of bandage, 
the starch should be prepared so as to be of the same 
consistence as that used in the laundry. Before ap- 
plying the roller, two compresses made of some soft mate- 
rial, folded so as to be at least one inch in thickness and 
of the same breadth as the limb, should be applied along 
each side, extending from the point at which the application 
of the bandage begins to the point at which it terminates. 
Holding these carefully in position, the first roller is ap- 
plied to the limb. This roller is now thoroughly coated 
with the starch by means of a medium-sized paint-brush, 
the interstices and spaces being well filled. Over this a 
second roller is applied and coated with the starch in the 
same manner. In this way a sufficient number of rollers 
should be applied until the parts are properly supported. 
If necessary, strips of pasteboard which have been soaked 
in the starch may be placed on the sides of the limb, after 
the second bandage has been applied, about those points 
requiring most support. 

The compresses, which are placed on the sides of the 



76 BANDAGING. 

limb, serve the purpose of protecting it from undue pres- 
sure, caused by the drying of the starched bandages. 
They may be applied dry, or they may be soaked in the 
starch and then applied. In the leg they are especially 
serviceable in preventing pressure over the crest of the 
tibia, the two borders of the compresses which are sepa- 
rated to a slight extent supporting the bandage and keeping 
it from too close contact with the limb. 

2. The Plaster of Paris Bandage. This bandage 
may be applied with rollers made of some loosely woven 
material, such as crinoline, Swiss muslin, or mosquito- 
netting, or with the ordinary muslin. When the first is 
used, it should be cut into strips, and dry plaster rubbed 
with the hand into its meshes on both sides; and then the 
strips should be formed into rollers and put in an air-tight 
tin vessel. When required, the rollers should be placed 
on end in a basin, containing water enough to cover them 
entirely, for one or two minutes, in order that they may 
become thoroughly wet, and in this condition they should 
be applied rapidly to the part; a free escape of bubbles 
of gas through the water takes place, and, when this has 
ceased, the bandages are ready for application. 

The roller, made'of the ordinary muslin, can be prepared 
by unrolling it in a basin containing water, thus becoming 
wet as it unrolls, and re-rolling it in a basin containing a 
mixture of plaster and water of the consistency of cream. 
In this way the surfaces become well coated with the plas- 
ter, and the roller can be applied directly to the part. 
In applying the plaster bandage, the mixture of plaster 
should be rubbed over each roller with the hand after it is 
applied . The setting of the plaster may be retarded by add- 



BANDAGING. 77 

ing a little size or stale beer. If salt is added, its tendency 
to set will be increased. Gum-water, white of egg, or 
flour-paste should be applied to the surface after hardening 
has occurred, in order to prevent chipping; a coat of var- 
nish will render it impermeable to moisture. In this form, 
the compresses should be placed along the sides of the 
limb in the same manner as in the starch bandage. 

3. The Silica Bandage. In preparing this bandage 
a solution of the silicate of potassium or sodium is used. 
The roller is applied to the limb over the compresses, 
placed as above described, and it is thoroughly coated 
with the solution by means of a medium-sized painter's 
brush. As many rollers as may be deemed necessary are 
applied, each being thoroughly coated with the solution. 

This is an excellent form of the immovable bandage, 
being easily applied, lighter than the plaster bandage, and 
hardening in a very short time. 

In addition to these forms of immovable bandages there 
are the Dextrine, the Gum-and-Chalk, the Glue, and the 
Paraffin bandages. These do not possess any advantages 
over those described above ; the end to be accomplished 
— immobility of the parts — being secured by one as well 
as by the other. 

Great caution should be observed in applying the rollers 
in these forms of bandage lest too much traction be em- 
ployed; they should be applied with less traction than the 
ordinary roller, owing to the shrinkage which occurs, and 
which thus increases the pressure. The parts should be 
carefully watched after the application has been made, in 
order to note any changes which may occur, indicating too 
much pressure or interference with the circulation. Should 

7* 



78 



BANDAGING. 



Fig. 60. evidences of these conditions manifest 

themselves, the bandages should be im- 
mediately removed, the limb sponged 
with soap liniment or alcohol and lauda- 
num, and the dressings re-applied with 
more care. 

In some forms of the immovable ban- 
dages, great difficulty is experienced in 
effecting their removal. Strong-cutting 
pliers have been made, with which the 
bandages can be divided, the instrument 
being carried along the side of the limb 
(Fig. 60). The starch bandage requires 
to be removed by this instrument. The 
plaster of Paris bandage can be easily 
unrolled from the part, or, if very thick, 
dilute hydrochloric acid may be applied 
along the side for a few minutes, soften- 
ing the plaster, so that it can be divided 
by the scissors. The silica bandage may 
be readily removed after soaking it for a 
time in warm water. 

Sayre's Suspension Apparatus for 
applying the Plaster Jacket. This is 
an apparatus devised by Professor Lewis 
A. Sayre, of New York, for the purpose of suspending 
patients suffering from antero-posterior curvature of the 
spine during the application of the plaster of Paris ban- 
dage. The object to be accomplished by the suspension 
of the patient, is the separation of the diseased vertebrae, 
and the straightening, to a certain extent, of the column, 



BANDAGING. 



79 



the bandage being applied when the patient is suspended. 
When it hardens, it prevents the recurrence of the curva- 
ture to the same extent as before, by offering a firm sup- 
port to the parts. 

The apparatus consists of a curved iron cross-beam, to 
which is attached an 



adjustable head and 
chin collar, with 
straps fitted to axil- 
lary bands. To a 
hook in the centre 
is fixed a compound 
pulley, the other end 
of which is secured 
either to a hook in 
the ceiling, or to the 
top of an iron tripod 
about ten feet in 
height (Fig. 61). In 
applying the plaster 
jacket, "the surface 
of the skin should 
be protected by an 
elastic but closely 
fitting shirt or vest, 
without armlets, with 
tapes to tie over the 
shoulders, and com- 
posed of some soft, 
warm, or knitted 
material ;" a thin 
and closely fitting 



Fig. 61, 







8o 



BANDAGING. 



Fig. 62. 



merino undershirt can be thus prepared. When the pa- 
tient is a developing girl, pads should be placed over each 
breast, to be removed just before the plaster has com- 
pletely set. Another pad, 
composed of cotton loosely 
folded up in a handker- 
chief, is to be placed over 
the abdomen; it should be 
very thin at its lower part, 
so as not to make the jacket 
too loose. On the same 
principle, small pads are 
applied at either side of 
tender spots over promi- 
nent bony processes, and 
two folded cloths, three or 
four thicknesses each, just 
over the anterior iliac 
spines. The shirt being 
accurately applied, and 
kept smoothly stretched by 
means of the shoulder- 
tapes above and two tapes 
below, one in front and 
the other behind, tied over 
a handkerchief placed in 
the perineum, the patient is 
to be drawn up gently tmtil 
he feels comfortable (Fig. 
62). 

A prepared and saturated 
roller, gently squeezed so 
as to get rid of all surplus 




BANDAGING. 8 1 

water, is now applied around the smallest part of the body, 
and carried around the trunk downwards to a little below 
the crest of the ilium, then spirally from below upward 
until the entire trunk is encased from the pelvis to the 
axillae. The bandage should be applied smoothly, and 
not drawn tight. 

" After one or two thicknesses of bandage have been 
thus applied, several narrow strips of roughened tin are 
laid on either side of the spine, so as to surround the 
body, with intervals between them of two or three inches. 
Over these another plaster bandage is applied ; very soon 
the plaster sets so firmly that the patient can be removed 
and laid upon his face or back upon a hair-mattress or 
air-bed. The pads are then removed, and the plaster 
gently pressed in with the hand in front of each iliac spine, 
so as to widen the case over the bony projections. While 
the patient is thus lying, it is sometimes necessary to wet 
the jacket with a little water, and then dust on some more 
plaster. As soon as the plaster has hardened, the patient 
may be allowed to walk about." 

The jacket is generally removed, after two or three 
months, by dividing it with the cutting pliers, knife, or a 
very narrow saw, from the pubes to the sternum, and 
gently stretching it apart. 



PART III. 

LIGATIONS 



Ligations are surgical procedures, and, as such, re- 
quire the employment of cutting instruments. In per- 
forming them, the methods of holding the knife, of making 
the incisions, and of closing the wound, vary. 

Positions of the Knife. There are three principal 
positions in which the knife may be held. In the first 

Fig. 63. 




position (Fig. 6$), it is held as the pen in writing, the cut' 
ting edge being turned downward or upward. 

( 82 ) 



POSITIONS OF THE KNIFE. 



83 



In the second 
position (Fig. 
64), the handle 
of the instru- 
ment is grasped 
firmly in the 
hand as a table- 
knife is held. 
The handle lies 
in the palm, sup- 
ported strongly 
between the 
thumb, middle, 
ring, and little 
fingers, whilst 
the index finger 
is slightly ex- 
tended along 
the back of the 
blade. In using 
the knife in this 
position, the 
cutting edge may 
be turned up- 
ward or down- 
ward . 

In the third 
position (Fig. 
65), the knife is 
held as the bow 
of the violin 



Fig. 64. 




Fig. 65. 




Fis- 66. 




lightly balanced between the thumb and fingers. In this 



84 LIGATIONS. 

position, also, the edge may be turned upward or down- 
ward (Fig. 66). 

Incisions. The incisions which are employed may be 
straight, curvilinear, or angular, and may be made 
from without inward or from within outward. 

The straight incision (Fig. 67) is that most commonly 
used, and may be made in a vertical, oblique, or trans- 
verse direction. 

The curvilinear incision (Fig. 68) is used where it is 

Fig. 67. Fig. 68. Fig. 69. 

- r\ o L v H 

desirable to conform to the shape of the part involved, or 
where large space is required for the purposes of the ope- 
ration. Two curvilinear incisions meeting at their ex- 
tremities form the elliptical (Fig. 68). 

The angular incision (Fig. 69) is composed of two or 
more straight incisions placed at different angles — as the 
right angle forming the letter L, or the acute angle form- 
ing the letter V, etc. 

In making incisions from without inward, the integu- 
ment should be put upon the stretch; by this plan the 
incision is made with precision, and the integument is pre- 
served. In order to make the incision from within out- 
ward, a fold of the integument should be held up and its 
base transfixed by the knife, which should cut its way out. 
This method is employed where great caution is required 
in dividing the superficial tissues. The knife should be 
held lightly yet firmly, and the movements necessary to 
carry it through the tissues should, as a rule, be made with 



SUTURES. SS 

the fingers, and not at the wrist or elbow-joint. Very 
long incisions may require a sweeping movement made 
with the entire arm. In cutting from without inward, the 
edge of the knife should be held lightly in contact with 
the surface, not pressed into the tissues. " Dexterity, grace, 
and elegance," in using the knife, can be acquired only by 
practice and careful study. 

Closure of Wounds. In order to retain the edges of 
wounds in close apposition, so that union may take place, 
the introduction of sutures is necessary. 

The Sutures. The material used may be silk or linen, 
animal tissue or metal. The metallic suture may be made 
of silver, iron, or lead-wire. The suture may be fastened 
by a square knot, or, as in the metallic suture, by twisting 
the ends or clamping shot upon them. When the metallic 
suture is used in a cavity, as the mouth or vagina, the cut 
ends can be covered by clamping a shot on them, so as to 
prevent them from penetrating the tissues, and thus causing 
pain. The knots or twisted ends should always be placed 
on the side of the incision, and not over it. 

The principal forms of sutures employed are the inter- 
rupted, the continued, the twisted, and the quilled. 

The interrupted, continued, and quilled sutures are made 
by the insertion of a needle armed with a thread made of 
silk, linen, or wire. 

In the interrupted suture (Fig. 70) the needle is carried 
through the edge of the wound from without inward, at a 
proper distance from the border, across the wound, and 
pushed from within outward at exactly the same point on 
the opposite side. The thread is then cut, and another 
suture introduced either above or below. 



86 



LIGATIONS. 



The continued suture (Fig. 71) is made by passing the 
needle diagonally from one side of the wound to the other. 




Fig. 71. 



Fig. 72. 





Fig. 73- 



In this suture, the thread is not cut until a sufficient num- 
ber of sutures have been introduced to hold the edges in 
apposition. 

The quilled suture (Fig. 72) is formed by passing 
through the lips of the wound a needle armed with a 
double thread. The ends of the 
thread are tied over pieces of quill, 
bougie, or light wood, placed paral- 
lel to the edge of the incision. 
This suture is employed in approxi- 
mating the edges of deep wounds. 

The twisted suture (Fig. 73) is 

made by introducing a pin made 

of steel, commonly called the hare-lip pin, through the 

edges of the wound, and carrying a thread round it in an 

elliptical manner, so as to. hold it in place. The pin is 




NEEDLES. 



87 



1 



passed through Fig. 74. 

the deeper parts __^__ 

of the wound, ap- 
proximating them, 
while the thread 
brings the super- 
ficial portions in 
contact. 

Needles. The 
needles employed 
to pass the threads 
in forming sutures 

may be either straight or curved, round, triangular, or 
(Fig. 74). They may be mounted on 




^^ 



J.H.GEMRIG. 



double-edged 




handles, and may be cannulated (Fig. 75), and provided 
with special appliances for facilitating the passage of the 
thread or wire. 



OPERATIONS UPON THE LIVING AND DEAD SUBJECTS. 

As the knowledge of the student is to be acquired in 
operations performed upon the dead subject, it is important 



65 LIGATIONS. 

for him to understand that a marked difference exists with 
regard to the character of the tissues and the manner in 
which they separate under the edge of the knife in the 
living and the dead subjects. This difference should be 
carefully noted, so that when he undertakes operations 
upon the living subject he may avoid errors. 

In the living subject the soft tissues possess a great amount 
of elasticity and power of contractility. The former pro- 
perty resides to a marked degree in the common integu- 
ment, and thus adapts it in an admirable manner to the 
purposes of a common covering of the body. In the 
muscular structures the power of contractility is very great, 
varying, of course, in proportion to the size and amount 
of tissue involved. 

In the dead subject these conditions are entirely absent: 
it is true that in the recently dead subject a small amount 
may exist, but it may, however, be regarded as practically 
wanting. In the subject which has been injected with such 
an agent as chloride of zinc, and kept for a period of time 
in a solution of salt, elasticity and contractility of the tis- 
sues are not only absent, but there exists, in fact, as a result 
of this method of preservation, an induration which is 
altogether unnatural, and which impairs "to a great degree 
the value of the subject for anatomical or surgical purposes. 
The color and appearance of the tissues as well as the tex- 
ture are altered, so that these cannot be taken as guides in 
recognizing different structures. In the living subject a 
very slight exertion will carry a sharp knife easily and 
smoothly through the tissues — almost, it may be said to 
glide through without any effort on the part of the operator. 
In the dead subject, on the contrary, an effort is required 
to pass the knife through the structures, and in a subject 
prepared as above described, some force is necessary to 



LIGATION OF ARTERIES — INSTRUMENTS. 89 

divide them. The resistance offered by the tissues of the 
dead subject is well shown in the effort to introduce the 
catheter in the cadaver. Sometimes it is impossible to 
accomplish it, and even when done it has required so much 
force as to inflict injury upon the parts. The information 
derived from the operation is therefore of little practical 
value, since in the living subject the instrument is simply 
guided through the canal, passing almost by its own weight. 
The student will find, therefore, in passing from operations 
upon the dead to those upon the living subject, that unless 
he exercises great caution he will overestimate the resist- 
ance of the tissues and fail to make his incisions as con- 
templated. 

INSTRUMENTS USED IN THE LIGATION OF ARTERIES. 

Instruments. The instruments required to Fig. 76. 
perform operations for the application of liga- 
tures to arteries, are : 

1. A knife — That known as the scalpel, an 
instrument having a sharp point and a broad 
body or belly (Fig. 76). 

2. A pair of dissecting forceps (Fig. 11) to 
seize and hold the tissues, as may be necessary, 
in their division. The forceps should be held 
between the thumb and index and middle 
fingers. 

3. A grooved director — A blunt-pointed direc- 
tor, from four and a half to five inches in length, 
with a groove upon its upper surface (Fig. 77). 
It is used to introduce beneath layers of tissue 
before dividing them, and also to separate the 
delicate fascia enveloping vessels. 

8* 



9o 



LIGATIONS. 



4. A Ligature Needle — A curved, blunt pointed needle 
having an eye near its point, and mounted in a handle so 
as to enable it to be conveniently carried around the 
artery (Fig. 78). 

5. Ligatures — Threads made of various materials: silk, 
flax, animal tissue, or metal. They should be cut from 
fourteen to eighteen inches in length. 



Fig. 77. 



Fig. 78. 



Fig. 79. 





6. Spatulas — Instruments formed from metal, curved at 
one extremity, and of sufficient length and breadth to 
hold conveniently the edges of the wound apart (Fig. 79). 



GENERAL CONSIDERATIONS. 



9 l 



7. Scissors — The ordinary straight surgical scissors. 

8. Suture needles. 

9. Sutures. 

In performing the operation upon the living subject, 
there would be needed, in addition, adhesive plaster, cut 
into strips, to support the edges of the wound, a compress 
to cover the surface of the wound, and a roller to confine 
the dressings and afford gentle support to the parts. 

OPERATIONS FOR THE LIGATION 
OF ARTERIES. 

General Considerations. In order to perform the 
operation for the ligation of arteries properly, it is essential 
that the student should have a thorough knowledge of the 
anatomical relations of the structures concerned in the 
operation. He should be able, as it were, to see through 
the parts — to have a mental picture of the structures, layer 
after layer, from the surface to the position occupied by 
the vessel. He should have such familiarity with the ap- 
pearance of the various tissues as will enable him to dis- 
tinguish them promptly — their color and the arrangement 
of their fibres. He should know so well the course of 
the vessel that he can make the incision directly over and 
parallel to it, and not across it. He should not commence 
the incision by hunting for the artery, but should proceed 
intelligently, seeking as he advances for well-known and 
well-established guides or landmarks, structures of import- 
ance and having important relations to the vessel he seeks. 

The student, in operating upon the cadaver, is especially 
cautioned against want of care and undue haste ; it is too 
frequently observed that many are satisfied with simply 
finding the vessel, without possessing any definite knowl- 



92 LIGATIONS. 

edge with regard to its position and relations. As a result 
of such imperfect methods it not unfrequently happens 
that the ligature is found to surround a vein, nerve, ten- 
don, or even a portion of muscular tissue or fascia, 
instead of the artery. 

Every operation performed for the ligation of an ar- 
tery can be divided into three well-defined stages. The 
first stage embraces that part of the operation which 
relates to reaching or exposing the artery or its sheath ; 
the second includes the isolation or separation of the 
artery from the surrounding or accompanying struc- 
tures : in the third, the operation is completed by the 
application of the ligature and the closure of the wound. 
It is in the first stage of the operation that the anatomical 
knowledge of the operator is especially to be brought into 
play. He should carefully inspect the limb or part so as to 
fix the important external landmarks or surface markings; 
he should also feel it, so as to determine the nature of the 
structures causing projections upon the surfaces. He 
should fix accurately the points between which the vessel 
passes, and define its course ; he should recall its general 
relations in its entire extent, and its particular relations at 
the point of ligation. He should note carefully the char- 
acter of the structures having particular relations, whether 
bloodvessels or nerves, and therefore to be approached 
with great caution, or muscles or tendons which serve as 
rallying points or guides. After the incision of the skin 
and superficial fascia has been made, these guides should 
be sought for in order until the vessel is reached. 

When the artery has a sheath, inclosing with it a vein 
or a vein and a nerve, its isolation should be effected with 
great care, so as to avoid inflicting injury upon the accom- 
panying structures. 



GENERAL CONSIDERATIONS. 93 

As the coats of the artery receive their vascular supply 
from the nutrient vessels which ramify in the loose areolar 
tissue connecting the artery with the sheath, it is important 
that this should be destroyed to as slight an extent as pos- 
sible. As a rule, the separation should not be more than 
one-half of an inch. This rule should be observed in 
separating the artery from surrounding structures, under 
all circumstances, as suppuration is more liable to occur 
when the tissues are much disturbed and broken up. 

In passing the ligature around the artery, the point of 
the instrument should be carried always from the vein, so 
that the point cannot penetrate it; if a vein is not present, 
then the ligature should be passed from the nerve. If the 
vessel is accompanied by venae comites, these should be 
gently separated before passing the ligature. Before 
tying the ligature, careful examination should be made to 
see that the nerve is not included. 

In making the incisions to expose the artery, the skin 
over the part to be divided should be held firmly between 
the thumb and index finger of the left hand, while the 
knife, held in the position of the pen in writing, should be 
introduced in a vertical direction, the point penetrating 
the skin, and, to a slight extent, the superficial fascia; 
then, depressing the handle of the knife, it is drawn down- 
ward or upward as the case may be, dividing the tissues 
to the proper extent, and withdrawn in the vertical direc- 
tion, the movements necessary to accomplish this being 
made by the fingers and at the wrist-joint. This first 
incision should be free, and cleanly cut. The fascia is 
now seized by the dissecting forceps at the lower angle of 
the incision, elevated, and a small incision is made with 
the scalpel (Fig. 80). Through this opening the point 



94 



LIGATIONS. 



of the grooved director is introduced, and gently pushed 
to the upper angle of the incision. The knife is now 



Fig. 80. 



Fi°:. 81. 




carried along the groove (Fig. 66), dividing the fascia 
and liberating the director. Before incising the fascia 
raised upon the director, it should be examined carefully 
in order to detect any vessels or nerves which it may con- 
tain. If these are of sufficient importance they can be 
held aside, while the fascia is divided, or, if necessary, 
the vessels may be ligated and then divided. Each layer 
of tissue is to be divided in this manner until the sheath 
of the artery is reached. This is opened by seizing it 
with the forceps and making a slight nick, of sufficient 
size to admit the point of the ligature needle. Through 



GENERAL CONSIDERATIONS. 95 

this opening the point of the grooved director is inserted, 
and the artery is gently and cautiously separated from the 
sheath and the accompanying structures. The ligature 
needle, having been armed, is now introduced through 
the opening, the point kept in close contact with the artery 
and carried around it in a direction from the vein or nerve 
and brought out on the opposite side. One thread of the 
ligature is now seized with the forceps, and held firmly 
while the needle is withdrawn. 

The artery thus surrounded should be raised gently 
from its bed, and examined to see that no other structure 
is included in the ligature. This being determined, the 
ligature is tied with a square or reef knot (Figs. 81, 82), 

Fig. 82. Fig. S3. 





care being taken to avoid making the "granny" knot, 
which is liable to slip (Fig. 83) ; one end is cut off close 
to the knot, and the remaining one is allowed to pass 
directly out of the wound. 

The wound is now closed by two or more sutures, the 
knots being placed on one side of the incision and not 



96 LIGATIONS. 

over it, adhesive strips and compress are applied, and the 
parts gently supported by a few turns of the roller. 

Some of the more important points relating to the differ- 
ent steps of the operation may be embraced in a few gene- 
ral rules, which will assist the student in fixing them upon 
his mind. 

I. Make the incision directly over and parallel to the 
course of the artery, not across it. Unless the incision is 
made very wide of the course of the vessel, this plan will 
give ample room. The tissues can be separated by the 
spatulas, so as to increase the space, when required. If 
the oblique incision is made, and is carried into the deeper 
part of the wound, the muscular structures would be divided 
across their fibres, which is objectionable, and not parallel 
with them. 

II. Dissect directly down to the artery. Avoid lateral 
dissections and disturbance of the surrounding structures. 

III. Separate the artery from its sheath to the slightest 
extent possible. 

IV. Do not use the point of the knife in the wound after 
the sheath of the vessel has been reached and opened. 
Use the handle of the knife and the grooved director to 
separate tissues. 

V. Always pass the ligature from the vein, if present. 

VI. Make the incision as small as possible, but always 
large enough to give ample working space and light. 
The external incision should be made to the extent re- 
quired by the first stroke of the knife, so as to avoid sub- 
sequent incisions to enlarge it. These, when made, 
usually result in the production of irregular, jagged 
edges. A superficial artery requires a short incision, one 
lying deeper a longer incision. 



GENERAL CONSIDERATIONS. 97 

VII. In closing the wound, the needle should be in- 
serted at such distance and depth from the edge as to 
resist tension, — as a rule, not less than half a line, nor 
more than a quarter of an inch. Two-thirds of the thick- 
ness of the edge should be supported by the suture. 

In describing the ligations of the various arteries, a plan 
has been adopted which, it is thought, will assist the 
student materially, not only in performing the operations, 
but in studying them. An effort has been made to pre- 
sent the subject in a systematic manner, so that when the 
operation is undertaken the student will find information 
which will enable him to proceed intelligently through 
each step, and, when finished, study it as a complete 
operation. 

In each description the following order has been ob- 
served : -— 

I. The course of the vessel is stated, the direction 
which it takes in passing between certain points — fixed or 
imaginary. 

II. External guides or surface markings are given. 
These may exist as bony projections or borders of mus- 
cles which appear prominently upon the surface ; they 
are important in fixing the relations of the vessel to the 
external surface. 

III. The general anatomical relations which the vessel 
has are given in detail, and also the particular relations 
at the point of ligation. These acquaint the student with 
the entire surroundings of the vessel, informing him of 
their nature. 

IV. Internal guides, landmarks, or rallying points, 
which are to be sought for as the operation progresses, 
are noted in each case. 

9 



9 8 



LIGATIONS. 



V. Certain structures, as veins and nerves, have rela- 
tions to each important artery, and are to be carefully 
avoided. These are stated in the order of their import- 
ance, and in certain operations special attention is directed 
to their presence. 

VI. Some of the larger arteries are embraced in a 
common sheath with the vein, and sometimes a nerve. 
When this arrangement exists it is stated. 

LIGATION OF SPECIAL ARTERIES. 

The Innominate Artery. Surgical Anatomy.— Before 
attempting to ligate this vessel the student should endeavor 
to obtain a clear idea of the relations it has to the very 
important structures which surround it. It is the largest 
branch given off from the arch of the aorta, and is from 
an inch and a half to two inches in length (Fig. 84). Its 



Fig. 84. 




Innominate Artery. 



1.1. Internal jugular veins. 

2.2. Subclavian veins. 

3. Right innominate vein. 

4. Left innominate vein. 

5. Inferior thyroid vein. 

6. External jugular vein. 

7. Arch of the aorta. 

8. Innominate artery. 

9,9. Common carotid arteries. 
10, 10. Subclavian arteries. 



point of origin, from the transverse portion of the aorta, 
is about one inch below the margin of the sternum, and 
on a line with the second costo-sternal articulation. It is 
in intimate relation with the two large venous trunks — the 
right and left innominate veins— the right inferior thyroid 



THE INNOMINATE ARTERY. 99 

vein crossing its front in an oblique direction. On the 
right side it has in close proximity the right pneumogastric 
nerve and the pleura ; it rests upon the trachea, and to the 
left has in relation the left carotid artery. It will be ob- 
served, therefore, that on all sides are placed the most 
important structures, which require the utmost care to 
avoid. Not only should these structures be carefully 
guarded against injury, but in any operation which is per- 
formed they should be disturbed to the slightest extent 
possible. The causes of failure in efforts which have been 
made to surround this vessel with a ligature in the living 
subject are stated to have been repeated secondary 
hemorrhages and inflammation of the pleura and lung. 

Course — Obliquely upward from point of origin from 
the commencement of the transverse portion of the arch 
of the aorta to the sterno-clavicular articulation of the 
right side. 

Surface markings — Sterno-clavicular articulation. Fossa 
above the clavicle, indicating the interval between the two 
heads of the sterno-cleido-mastoid muscle. 

General relations: In front — Sternum, sterno-hyoid, 
and sterno-thyroid muscles; remains, of thymus gland; 
left innominate and right inferior thyroid veins, and car- 
diac branches of the right pneumogastric nerve. 

Behind — The trachea. 

Right side — Right innominate vein, pneumogastric 
nerve, and the right pleura. 

Left side — Remains of the thymus gland and the left 
carotid artery. 

Guide — The sterno-cleido-mastoid muscle. 

Structures to be avoided — The middle and right inferior 
thyroid, the anterior and internal jugular, and the right 
innominate veins; the pneumogastric nerve. 



IOO LIGATIONS. 

Operation.— Raising the shoulders, inclining the head 
slightly backward and to the left side, so as to render 
tense the right sterno-mastoid muscle, and project the in- 
nominate artery into the neck, an incision, three inches in 
length, dividing the skin, should be made from below the 
clavicle upward over the fossa, indicating the interval be- 
tween the two heads of the sterno-mastoid muscle. The 
superficial fascia, platysma myoides, and anterior layer of 
the deep fascia, are now carefully divided on the grooved 
director. Flex the head slightly, and separate with the 
fingers the heads of the sterno-mastoid muscle, the con- 
necting areolar tissue having been divided. Divide care- 
fully on the director the deep layers of the cervical fascia, 
and, if necessary, the sterno-hyoid and sternothyroid 
muscles transversely. These incisions will expose the 
point of bifurcation of the artery into the carotid and sub- 
clavian arteries. Passing downward from this point the 
artery can be reached, and the ligature applied from right 
to left, so as to avoid the right innominate vein (Fig. 85). 
The innominate artery can also be reached by an incision, 
two inches in length, made along the anterior border of 
the sterno-mastoid muscle, terminating at the clavicle. 
From this point a second incision, to the same extent, is 
carried along the upper border of the clavicle. The 
points of attachment of the platysma, the sterno-mastoid, 
sterno-thyroid, and sterno-hyoid muscles are to be divided 
as they are exposed. Dividing carefully the fascia, and 
separating other structures, the right carotid artery is 
brought into view; tracing this downward, the innominate 
artery can be reached and ligated. 

The advantages claimed for the method first described 
are, in avoiding the section of the muscles, and the greater 



THE INNOMINATE ARTERY. 



lOI 



ease with which the artery is approached. While, in all 
cases, it is desirable to divide the tissues to as slight an ex- 




1. Internal head of sterno-mastnd muscle. 
2 External head of sterno-mastoid muscle. 

3. Vertebral artery. 

4. Pneuinogastric nerve. 

5. Recurrent laryngeal nerve. 

6. Internal jugular vein pulled aside. 

7. First part of subclavian artery and its branches. 

8. Innominate artery. 

tent as possible, it is, nevertheless, of great importance 
that the operator should not be embarrassed by want of 
ample working space. Great injuries may be inflicted 
upon structures in the effort to save those of less import- 
ance. In this operation it is sometimes impossible to avoid 



102 



LIGATIONS. 



wounding some of the larger venous branches in relation 
with the artery; when this occurs they should be ligated, 
or, when it is necessary to divide them, two ligatures 
should be applied, and the vein cut between. 

The Triangles of the Neck. Before passing to the 
operations upon the arteries which occupy the region of 
the neck, the student should, in connection with the study 
of their relative anatomy, also carefully examine these 
structures collectively. On examination it will be found 
that these vessels, with other important structures, occupy 



Fig. 86. 




Posterior belly of the di- 
gastric muscle. 

Anterior belly of the digas- 
tric. 

Anterior belly of the omo- 
hyoid muscle. 

Posterior belly of the omo- 
hyoid. 

Sterno-cleido-mastoid mus- 
cle. 

Trapezius muscle. 

Digastric, or submaxillary 
triangle. 

Superior carotid triangle, or 
triangle of election. 

Inferior carotid triangle, or 
triangle of necessity. 

Occipital triaugle. 

Subclavian triangle. 



Triangles of the Neck, 



certain well-defined spaces, which can be readily out- 
lined, and which are formed by prominent muscular and 
bony structures (Fig. 86). The side of the neck is some- 
what quadrilateral in shape: bounded above, by the lower 



THE TRIANGLES OF THE NECK. I03 

border of the body of the jaw and an imaginary line ex- 
tending from the angle of the jaw to the mastoid process 
of the temporal bone; below, by the upper border of the 
clavicle; in front, by the median line of the neck; and be- 
hind, by the border of the trapezius muscle. The sterno- 
mastoid muscle, crossing this space obliquely, divides it 
into two large triangles, the anterior and posterior. The 
former is bounded by the median line of the neck in front, 
the anterior border of the sterno-mastoid behind, and the 
border of the jaw and the imaginary line from the angle 
to the mastoid process above. This triangle is subdivided 
by the digastric and anterior belly of the omo-hyoid 
muscle into three smaller triangular spaces, named, from 
below upward, the inferior carotid, the superior carotid, 
and the digastric. 

The inferior carotid triangle, or the "triangle of neces- 
sity," as it is sometimes designated, is formed by the 
median line of the neck in front, by the anterior border 
of the sterno-mastoid behind, and by the anterior belly of 
the omo-hyoid above. The common carotid artery passes 
through this space obliquely upward and backward, fol- 
lowing the direction of the sterno-mastoid muscle, covered 
in part by the muscles which take origin from the sternum 
and clavicle. 

The superior carotid triangle, or the "triangle of elec- 
tion," is bounded by the posterior belly of the digastric 
above, the anterior belly of the omo-hyoid below, and 
the anterior margin of the sterno-mastoid behind. In this 
space the common carotid artery lies superficial, and at 
the upper border of the thyroid cartilage divides into its 
terminal branches, the external and internal carotids. 

The digastric triangle is limited above by the lower 



104 LIGATIONS. 

border of the jaw, the parotid gland, and mastoid process 
of the temporal bone; behind by the posterior belly of 
the digastric and stylo-hyoid muscles, and in front by the 
anterior belly of the digastric muscle. The external and 
internal carotid arteries, with the internal jugular vein 
and pneumogastric nerve, pass through this space. 

The posterior triangle is subdivided into two smaller 
triangles, by the posterior belly of the omo-hyoid muscle, 
the occipital and the subclavian. 

The occipital triangle is bounded, in front, by the poste- 
rior border of the sterno-mastoid; behind, by the anterior 
border of the trapezius; and, below, by the posterior belly 
of the omo-hyoid. 

The subclavian, the smaller and more important of the 
posterior subdivisions, is formed by the posterior border 
of the sterno-mastoid in front, the upper border of the 
clavicle below, and the posterior belly of the omo-hyoid 
above. In this space is found the subclavian artery as it 
arches across the root of the neck. 

The Common Carotid Artery. Surgical Anatomy. — 
For the purposes of ligation, the common carotid artery 
may be divided into two parts, that above the anterior 
belly of the omo-hyoid muscle extending to the point of 
bifurcation opposite the upper border of the thyroid car- 
tilage, and that below the muscle terminating at the sterno- 
clavicular articulation (Fig. 87). The upper portion lies 
in the superior carotid triangle (Fig. 86, b). Owing to the 
superficial position it occupies in this space, it is easily 
reached, and this is designated as the point of selection. 
At this part it is crossed obliquely from within outward 
by the sterno-mastoid artery, a branch of the superior 



THE COMMON CAROTID ARTERY. 



J °5 



thyroid (the superficial descending branch), and also by the 
facial, lingual, and superior thyroid veins, which terminate 

Fig. S 7 . 




1. Sterno-thyroid muscle. 

2. Gmo-hyoid muscle. 

3. 3. Extremities of the 
Sterno - cleido - mastoid 
muscle which has been 
divided. 

4. Masseter muscle. 

5. Common carotid artery, 
with filaments of descen- 
dens noni nerve on its 
anterior surface. 

6. Internal jugular vein. 

7. Pneumogastric nerve. 

8. External carotid artery. 

9. Facial artery with vein. 

10. Internal carotid artery. 

11. Hypoglossal nerve 
crossing the external ca- 
rotid artery. 

12. Liugual artery. 



The Common Carotid Artery. 



in the internal jugular. Below the omo-hyoid muscle the 
vessel occupies. the inferior carotid triangle (Fig. 86, c). 
Here it is deeply placed, lying beneath the sterno-mastoid, 
sterno-thyroid, and sterno-hyoid muscles, which arise 
from the adjacent parts of the sternum and clavicle. 

In this position, which is designated the triangle of 
necessity, its relations are somewhat more complicated 
than above, owing to the proximity of the vessels and 
other structures which converge to the root of the neck. 
On the right side the internal jugular vein separates from 
the artery, while on the left it approaches, and usually 
crosses, its lower part, in order to unite with the sub- 
clavian vein. 



lo6 LIGATIONS. 

It is also to be remembered that the carotid arteries 
present frequently peculiarities relating to origin, point of 
bifurcation, and branches. In a surgical point of view, 
the most important peculiarity is that which relates to the 
point of division in the neck. In the order of infrequency, 
the points of division are given as the root of the neck, 
opposite the middle of the larynx or lower border of the 
cricoid cartilage, opposite the hyoid bone or beyond this 
point. 

The artery occasionally gives origin to the superior 
thyroid or a laryngeal branch, the inferior thyroid or, 
very rarely, the vertebral artery. 

After ligation of the common carotid artery, the col- 
lateral circulation is freely established both within and 
without the cranium by the branches of both carotid 
arteries and those of the subclavian artery on the side on 
which ligation has been performed. Outside, the superior 
and inferior thyroid and the profunda cervicis of the 
superior intercostal and arteria princeps cervicis of the 
occipital form the principal channels of communication, 
while, within the cranium, the vertebral artery takes the 
place of the internal carotid. 

Course — From the sterno-clavicular articulation upward 
and backward to a point midway between the mastoid 
process of the temporal bone and the angle of the lower 
jaw. 

Surface marking — The sterno-cleido-mastoid muscle. 

General relations. Above the Omohyoid Muscle : In 
front — Skin, superficial fascia, platysma and deep fascia, 
anterior border of sterno-mastoid muscle, facial, lingual, 
and superior thyroid veins, sterno-mastoid artery, descen- 
dens noni nerve. 



THE COMMON CAROTID ARTERY. TO 7 

Below the Omo-hyoid Muscle : In front — Skin, super- 
ficial fascia, platysma and deep fascia, sternal head of the 
sterno-mastoid, sterno-hyoid and thyroid muscles, ante- 
rior jugular and middle thyroid veins. 

Behind — Longus colli and rectus anticus major muscles, 
sympathetic nerve, inferior thyroid artery, and recurrent 
laryngeal nerve. 

Inside- — Pharynx, larynx, inferior thyroid artery, recur- 
rent laryngeal nerve, thyroid gland, and trachea. 

Outside — Internal jugular vein and pneumogastric nerve. 

Guide — The sterno-cleido-mastoid muscle. 

Structures to be avoided — Internal and anterior jugular 
veins, sterno-mastoid artery, descendens noni, and pneu- 
mogastric nerve. In the lower portion, the inferior 
thyroid artery, recurrent, laryngeal, and sympathetic 
nerves. 

Common sheath — Including the artery on the inside, 
internal jugular vein on the outside, and the pneumogas- 
tric nerve behind and to the outside. 

Operation. — Above the omo-hyoid muscle ; in the tri- 
angle of election. 

The head being thrown back and the face turned to the 
opposite side, an incision, from two and a half to three 
inches in length, is made, beginning opposite the greater 
cornu of the hyoid bone and passing downward along 
the anterior border of the sterno-mastoid muscle, dividing 
the skin. The superficial fascia, platysma muscle, and 
the layers of the deep fascia being divided carefully upon 
the director, the inner edge of the sterno-mastoid muscle is 
exposed. Lying beneath this, separated by a layer of the 
deep fascia, is found the common sheath of the vessels, 
with the descendens noni nerve upon its anterior surface. 



io8 



LIGATIONS. 



Pushing this gently aside, the common sheath is now to 
be opened to a very slight extent, the artery separated 
gently from the vein and nerve, and the ligature passed in 
a direction from the vein, being careful to avoid the nerve 

(Fig. 88). 

Fig. 88. 




1. Anterior belly of the omo-hyoid muscle. 

2. Common carotid artery, with descenders noni nerve on its anterior surface. 

3. Internal jugular vein. 

4. Pneumogastric nerve. 

5. Sterno-mastoid muscle drawn aside. 



Operation. — Below the omo- hyoid muscle in the triangle 
of necessity. 

An incision from two and a half to three inches in 
length should be made from opposite the cricoid cartilage 
to a point one-quarter of an inch above the sternum along 
the inner edge of the sterno-mastoid muscle, dividing the 
skin. The superficial fascia, platysma, and the layers of 
the deep fascia should be carefully divided upon the direc- 



THE COMMON CAROTID ARTERY. IOQ 

tor, exposing the sterno-mastoid muscle. Turning the 
head towards the side operated on, and slightly flexing it, 
so as to relax the muscles, the sterno-mastoid is drawn to 
the outer side, and the sterno-hyoid and sterno-thyroid 
muscles to the inner side. The sheath of the vessels, 
lying beneath the layers of the deep fascia, which should 
be divided, is opened carefully, and the ligature passed 
from the vein, care being taken to avoid the pneumogas- 
tric and the descendens noni nerve, which latter here lies 
somewhat to the inner side (Fig. 88). 

In performing the operation above the omo-hyoid mus- 
cle, the student should bear in mind the direction which 
the anterior belly of this muscle takes in passing to its 
point of insertion on the hyoid bone, and the point at 
which it crosses the artery. From its point of origin on 
the upper border of the scapula, it passes forward across 
the root of the neck, leaving the line of the upper border 
of the clavicle gradually until it reaches the sterno-mastoid 
muscle, behind which it becomes tendinous and changes 
its direction, ascending almost vertically upward to the 
hyoid bone, forming an obtuse angle. This direction 
takes it across the artery at a point slightly below the 
middle; as the ligature should be applied just above 'its 
upper border, the middle point of the artery should be 
ascertained, and the incision made so as to expose this 
part. This point corresponds to the lower border of the 
larynx, and can, therefore, be easily fixed. The upper 
part of the artery, just below the point of bifurcation, 
should not be chosen for the application of the ligature, 
owing to the position in front, of the facial, lingual, and 
superior thyroid veins. Attention is also directed to the 
intimate relation which the internal jugular vein has to the 
10 



HO LIGATIONS. 

artery; the large column of blood it carries brings it 
prominently into the wound, and the extreme thinness of 
its walls renders it liable to be easily wounded. 

In the operation below the omo-hyoid muscle, the rela- 
tions of the middle thyroid vein, the inferior thyroid 
artery, and the recurrent laryngeal nerve, with the posi- 
tion of the internal jugular vein across the artery at the 
root of the neck on the left side, should be borne in mind. 

The importance of the sterno-mastoid muscle as a guide 
to the carotid artery, should not be forgotten. In its 
entire extent it may be said to be covered and protected 
by this muscle, being placed well under it in the first part 
of its course, and gradually approaching its anterior bor- 
der as it ascends the neck. The muscle is embraced be- 
tween two layers of the deep cervical fascia, which unite 
at its anterior border. When the fibres of the muscle are 
exposed in the operation, it is to be remembered that but 
one layer of the envelope of the muscle has been divided, 
and that another lies beneath, separating the muscle from 
the sheath of the vessels, which must be divided before 
the sheath is reached. 

The External Carotid Artery. Surgical Anatomy. — 
Owing to the complicated relations of this vessel, and the 
number of branches given off from it, ligation, except in 
cases of wounds, is rarely performed. If necessary, a 
ligature may be applied near its origin or above the poste- 
rior belly of the digastric muscle. In the first part of its 
course, the artery lies in the triangular space formed by 
the sterno-mastoid behind, the anterior belly of the omo- 
hyoid below, and the posterior belly of the digastric above. 
In this space it is crossed by the facial and lingual veins 
and by the hypoglossal nerve below the tendon of the 



THE EXTERNAL CAROTID ARTERY. Ill 

digastric muscle. As it ascends it gets beneath the digas- 
tric muscle, and passes deeply into the substance of the 
parotid gland, where it is crossed by the facial nerve (Fig. 
87, 8). 

Course — From the upper border of the thyroid cartilage 
upward, forward, and backward to the space between the 
neck of the condyle of the lower jaw and the external 
auditory meatus. 

Surface markings — Sterno-mastoid muscle and posterior 
border of the ramus of the lower jaw. 

General relations : In front — Skin, superficial fascia, 
platysma muscle, deep fascia, hypoglossal nerve, facial 
and lingual veins, digastric and stylo -hyoid muscles. 

Behind — Superior laryngeal and glosso - pharyngeal 
nerves, stylo-glossus and stylo-pharyngeus muscles. 

Internally — Hyoid bone and pharynx, ramus of the 
lower jaw. 

Guides — Below, sterno-mastoid muscle ; above, poste- 
rior belly of the digastric muscle and the parotid gland. 

Structures to be avoided — Lingual and facial veins, and 
hypoglossal nerve. 

Operation. — At the point of origin of this artery the 
ligature may be applied by the same plan of operation as 
that adopted in the ligation of the common carotid artery 
above the omo-hyoid muscle (Fig. ZZ~). The incision is 
made from a point opposite the greater corn u of the hyoid 
bone, downward to the extent of two and one-half to three 
inches, dividing the skin. The superficial fascia, platysma 
muscle, and deep fascia are divided on the director, ex- 
posing the sheath of the vessel, which is opened, and the 
ligature is passed from without inward, care being taken 
to avoid the internal carotid artery which lies behind and 
somewhat external. 



112 LIGATIONS. 

Above the posterior belly of the digastric muscle, the 
artery is reached by an incision extending from the lobe 
of the ear to the great cornu of the hyoid bone, dividing 
the skin. The superficial fascia, platysma, and deep 
fascia are divided carefully on the director, exposing the 
parotid gland. The posterior belly of the digastric, with 
the stylo-hyoid muscle, are found below at the bottom of 
the wound, and are to be separated from the parotid gland 
above, when the artery will be exposed before its entrance 
into the substance of the gland. 

In ligating the artery at this point, the student should 
recall the position of the numerous venous trunks which 
occupy this region. Some of these are necessarily divided, 
and give rise to considerable hemorrhage, which compli- 
cates the operation. When necessary, these should be 
ligated with two ligatures, and then divided. If cut before 
ligation, and the amount of hemorrhage warrants it, a 
ligature should be applied as in the arteries. In this re- 
gion, also, there will be found most important structures, 
vessels, and nerves, which are to be dealt with cautiously. 

The Superior Thyroid Artery. Surgical Anatomy. 
— This vessel is the first branch of the external carotid 
artery, being given off just above the point of bifurcation 
(Fig. 87). It lies superficially in the triangle of election 
at the beginning of its course, and can be reached readily. 

Course — From the point of origin below the greater 
cornu of the hyoid bone upward and inward, then curv- 
ing downward and forward to the upper part of the thy- 
roid gland. 

Surface markings — Stern o-mastoid muscle and greater 
cornu of the hyoid bone. 






THE LINGUAL ARTERY. 



i*3 



Fig. 89. 



General relations — The same in the first part of the 
artery as those of the external carotid. 

Guide — Greater cornu of the hy- 
oid bone. 

Structure to be avoided — The su- 
perior thyroid vein. 

Operation. — The incision to be 
made in ligating this vessel is on 
the same line, but somewhat inter- 
nal to that made for exposing the 
external carotid. The superficial 
structures are to be divided, when 
the vessel will be brought into 
view, as it ascends (Fig. 89). 




The Lingual Artery. Surgical Anatomy. — This 
artery is the second branch of the external carotid given 
off from its anterior surface (Fig. 87, 12). 

Course — From the external carotid artery just below the 
greater cornu of the hyoid bone obliquely upward and 
inward, horizontally forward parallel to the greater cornu, 
and then vertically upward to the under surface of the 
tongue. 

Surface marking — Hyoid bone. 

General relations. First portion: In front — Skin, 
superficial fascia, platysma, and deep fascia. 

Behind — Middle constrictor muscle. 

Above — Hyoid bone. 

Below — Thyroid cartilage. 

Second portion : Infrofit — Superficial structures, with the 
digastric and stylo-hyoid muscles and hypoglossal nerve. 

Behind — Middle constrictor muscle. 



114 LIGATIONS. 

Below — Greater cornu of the hyoid bone. 

Above — Muscles of the tongue. 

Guides — Posterior belly of the digastric muscle and 
the hypoglossal nerve. 

Structure to be avoided — Hypoglossal nerve. 

Operation. — A transverse incision is made along the 
upper border of the hyoid bone from a point in the me- 
dian line of the neck a little below the symphysis of the 
lower jaw to near the border of the sterno-mastoid muscle, 
dividing the skin. The superficial fascia, platysma, and 
deep fascia should be divided on the director. Seek for 
the posterior belly of the digastric muscle and hypoglossal 
nerve. The artery will be found along the upper border 
of the great cornu of the hyoid bone just as it passes be- 
neath the hyoglossus muscle. If not found at this point, 
it may be necessary to divide the attachment of the hyo- 
glossus muscle in order to reach the vessel and apply the 
ligature. Care should be taken to avoid the hypoglossal 
nerve (Fig. 89). 

The Facial Artery. Surgical Anatomy. — This is 
the third branch given off from the anterior surface of 
the external carotid artery, and may be ligated as it passes 
over the border of the lower jaw, at the anterior inferior 
angle of the masseter muscle (Fig. 87, 9). 

Course — From the point of origin a short distance above 
the cornu of the hyoid bone, obliquely forward and up- 
ward to the submaxillary gland, through which it passes, 
and upward over the body of the lower jaw at the anterior 
inferior angle of the masseter muscle ; forward and upward 
to the angle of the mouth, upward along the side of the 
nose, terminating at the inner canthus of the eye. 



THE TEMPORAL ARTERY. II5 

Surface marking — Masseter muscle. 

Relations at Jhe point of ligation : In front — Skin and 
superficial fascia. 

Behind — Body of the lower jaw. 

Externally — The masseter muscle and facial vein. 

Internally — The depressor anguli oris muscle. 

Guide — The anterior inferior angle of the masseter 
muscle. 

Structure to be avoided — The facial vein. 

Operation. — Fix the position of the anterior inferior 
angle of the masseter muscle, and make an incision, one 
inch in length, in the line of the artery, dividing the skin. 
The superficial fascia and fibres of the platysma muscle 
being divided on the director, the arcery will be exposed 
with the vein to the outside. The ligature is to be passed, 
avoiding the vein (Fig. 89). 

The Temporal Artery. Surgical Anatomy. — This 
artery is the smaller of the two terminal branches of the 
external carotid, and takes its origin in the substance of 
the parotid gland at a point midway between the neck of 
the condyle of the lower jaw and the external auditory 
meatus. Two inches above the root of the zygoma, over 
which it passes, it divides into the anterior and posterior 
temporal branches. 

Course — From the interspace between the neck of the 
condyle of the lower jaw and the external meatus, directly 
upwards over the root of the zygoma. 

Surface marking — Root of the zygoma. 

General relations : In front — Skin, superficial fascia, 
attrahens aurem muscle, and dense fascia from over the 
parotid gland ; superficial veins and nerves. 



Il6 LIGATIONS. 

Behind — Zygomatic arch. 

Outside — External auditory meatus. 

Inside — Origin of masseter muscle. 

Guide — Zygomatic arch. 

Structures to be avoided — Temporal vein and branches 
of auriculo -temporal nerve. 

Operation. — An incision one inch in length and one- 
third of an inch in front of the tragus should be made in 
the line of the vessel, dividing the skin. The superficial 
fascia, attrahens aurem muscle, and parotid fascia are to 
be divided carefully on the director, and the artery will 
be found lying on the zygoma. The vein which lies to 
the outside should be avoided in passing the ligature 
(Fig. 89). 

The Occipital Artery. Surgical Anatomy. — The 
occipital artery is the first branch of the external carotid 
arising from the posterior part. 

Course — From the point of origin near the lower mar- 
gin of the digastric muscle obliquely upward across the 
internal carotid to a point between the transverse process 
of the atlas and the mastoid process of the temporal bone, 
then horizontally backward in a groove on the surface of 
the bone, and vertically upward to the occiput. 

Surface marking — Mastoid process of temporal bone. 

Relations at point of ligation : In front — Skin, aponeu- 
roses of the sterno-mastoid muscle, splenius, digastric, and 
trachelo-mastoid muscles. 

Behind — Complexus, superior oblique, and rectus posti- 
cus major muscles. 

Guide — Mastoid process. 

Structure to be avoided — Occipital vein. 



THE INTERNAL CAROTID ARTERY. 117 

Operation. — The artery can be reached by making an 
incision one inch and a half in length over its course from 
the mastoid process of the temporal bone to the external 
occipital protuberance, dividing the skin. The fascia, 
aponeuroses of the sterno- mastoid muscle, and the splenitis 
capitis muscle must be divided, when the artery will be 
exposed, and the ligature applied, avoiding the vein which 
lies to the outside (Fig. 89). 

The Internal Carotid Artery. Surgical Anatomy. — 
The beginning of the first portion of this vessel is quite 
superficial, contained, as it is, in the superior carotid tri- 
angle, and being on the same plane with, but behind, the 
external carotid (Fig. 87, 10). As it ascends it approaches 
the vertebrae lying above on the pre-vertebral structures. 
Ligation just above the point of bifurcation may therefore 
be performed. Above the point where it is crossed by 
the stylo-hyoid and posterior belly of the digastric mus- 
cles, its relations are so complicated that any operation 
performed with a view to apply a ligature will be attended 
by serious difficulties. 

Course — From the point of bifurcation of the common 
carotid artery opposite the upper border of the thyroid 
cartilage, vertically upward to the carotid foramen in the 
petrous portion of the temporal bone. 

Surface marking — Sterno-mastoid muscle. 

General relations : In front — Skin, superficial fascia, 
platysma, deep fascia, sterno-mastoid, digastric, and stylo- 
hyoid muscles; external carotid and occipital arteries; 
hypoglossal nerve, and parotid gland. 

Behind — Rectus anticus major muscle, and superior 
laryngeal nerve. 



Il8 LIGATIONS. 

Outside — Internal jugular vein and pneumogastric 
nerve. 

Inside — Pharynx, tonsil, and ascending pharyngeal 
artery. 

Guide — Inner edge of sterno -mastoid muscle. 

Structures to be avoided — Internal jugular vein, external 
carotid artery, and pneumogastric nerve. 

Operation. — The operation for ligating the artery just 
above the point of bifurcation is the same as that per- 
formed in ligating the external carotid at this point. The 
incision should be made along the anterior edge of the 
sterno-mastoid muscle, somewhat to the outside of that 
made in securing the external carotid, owing to the posi- 
tion of the internal behind the external carotid. 

The Subclavian Artery. Surgical Anatomy. — This 
vessel, on the right side, arises from the innominate artery 
behind the sterno-clavicular junction, and ascends ob- 
liquely outward to the inner border of the scalenus anticus 
muscle; outward, behind the muscle, and from the outer 
border obliquely outward and downward beneath the 
clavicle to the lower border of the first rib, terminating in 
the axillary artery (Figs. 90, 91). On the left side it 
takes origin from the transverse portion of the arch of the 
aorta, and ascends almost vertically to the inner border of 
the scalenus anticus muscle, taking then the same course 
as on the right side. The scalenus anticus muscle there- 
fore divides it into three parts: the first lying to the inner 
side, the second behind, and the third extending from the 
outer side to the lower border of the first rib. 

Ligation of the first and second parts is very rarely 
practised 3 the branches given off from the first part render 



THE SUBCLAVIAN ARTERY. 



119 



the operation extremely hazardous, as well as prevent com- 
plete interference with the circulation by means of the 

Fig. 90. 




The Axillary and Subclavian Arteries. 

1. Clavicle cut across. 

2. Pectoralis major muscle partially cut away. 

3. Trapezius muscle. 

4. Sterno-cleido-mastoid. 

5. Omo-hyoid. 

6. Deltoid. 

7. Pectoralis minor. 

S. The axillary artery. 
9. The axillary vein. 

10. The brachial plexus, above and behind. 

11. Supra-scapular artery. 

12. Cephalic vein passing in inter-space between deltoid and pectoralis major 
muscles to enter into axillary vein just above upper border of pectoralis minor 
muscle. 

13. External jugular vein. 




120 LIGATIONS. 

ligature. If it should become necessary, it can be reached 
by the same incision as is made in ligating the innominate 
artery. 

The second part lies deeply behind the muscle, and 
offers no advantage over the third 
part, which is readily reached. 

The third part has no branches, 
and is placed in a triangular space 
formed above by the posterior belly 
of the omo-hyoid muscle ; below by 
the clavicle, and to the inner side 
The Subclavian Artery. by the sterno-mastoid muscle. The 

1. Subclavian artery. s i ze Q f ^is space J g i ncre ased or di- 

2. Subclavian vein. . . 

3. First rib. mimshed by the extent of attach- 

4. scalenus anticus mus- ment f t h e sterno-mastoid and tra- 
de, between vein and ar- 
tery, pezius muscles to the clavicle, the 

proximity of the posterior belly of 
the omo-hyoid to the border of the clavicle, and the posi- 
tion of the shoulder, whether depressed or elevated. In 
this space the artery has important relations with the sur- 
rounding structures. The subclavian vein lies beneath 
the clavicle at this point of its course; occasionally it rises 
into this space, and is in relation in front. The brachial 
plexus of nerves lies above and in close relation to the 
artery; the supra-scapular vessels pass transversely across 
the space near the margin of the clavicle ; the transverse 
cervical nerves cross its upper angle; the external jugular 
vein passes down the neck along the posterior border of 
the sterno-mastoid, and empties into the subclavian vein ; 
it receives superficial veins, which lie in front of the 
artery. 

It is important to note the height to which the artery in 



THE SUBCLAVIAN ARTERY. 121 

its course rises in the neck. Normally, it may be said to 
extend to the height of one-half of an inch above the 
clavicle ; occasionally to the extent of an inch and a half, 
and sometimes its position is on a level with the upper 
border of the bone. Its relations with regard to the sca- 
lenus amicus also vary ; it has been found to pass in front 
or through the fibres of this muscle, and the vein is noted 
to have passed behind the muscle with the artery. 

Course : Right subclavian — From the sterno-clavicular 
junction to the lower border of the first rib, obliquely up- 
ward, then outward and downward. 

Left subclavian — From opposite the second dorsal ver- 
tebra to the lower border of the first rib almost vertically 
upward, then outward and downward. 

Surface markings — Posterior border of the sterno-mas- 
toid muscle, anterior border of the trapezius muscle, upper 
border of the clavicle, possibly posterior belly of the omo- 
hyoid muscle. 

Relations at point of ligation. Third portion : In front — 
Skin, superficial fascia, platysma muscle, deep fascia; 
external jugular, suprascapular, and transverse cervical 
veins ; branches of cervical plexus of nerves, suprascapular 
artery, subclavius muscle, and clavicle. 

Beliind — Middle scalenus muscle. 

Above — Brachial plexus of nerves and posterior belly of 
the omohyoid muscle. 

Beloiv — First rib. 

Guides in order from without inward — i. Posterior belly 
of the omo-hyoid. 2. Brachial plexus. 3. Scalenus ami- 
cus muscle. 4. Tubercle on first rib. 

Structures to be avoided — External jugular vein, supra- 
scapular artery, brachial plexus of nerves, subclavian vein. 
11 



122 



LIGATIONS. 



Operation. — Depressing the shoulder, so as to enlarge 
the subclavian triangle, an incision extending along the 
upper border of the clavicle from the posterior border of 
the sterno-mastoid to the anterior border of the trapezius 
should be made, dividing the skin. The superficial fascia 
and platysma should be divided on the director. The ex- 
ternal jugular vein, at the inner side of the wound, should 
be drawn aside ; if necessary to divide it, two ligatures 
should be applied, and the vein cut between. The bor- 
ders of the sterno-mastoid and trapezius may require 
division to give space. Avoid the suprascapular artery, 

Fig. 92. 




1. Brachial plexus of nerves. 

2. Subclavian artery. 

3. First rib. 

4. Scalenus anticus muscle. 

5. Posterior border of sterno mastoid muscle. 

separate the layers of deep fascia cautiously with the fin- 
ger, grooved director, or handle of the knife, and seek 
for the omo-hyoid muscle ; avoid the brachial plexus 



THE AXILLARY ARTERY. I 23 

above, and still further separate the fascia and seek for 
the scalenus anticus muscle, and trace it to its insertion in 
the tubercle on the first rib — to its outer side the artery 
crosses the rib, where it can be felt. Pass the ligature 
carefully from below upward (Fig. 92). 

The Axillary Artery. Surgical Anatomy. — The 
axillary is a continuation of the subclavian, beginning at 
the lower border of the first rib, passing downward through 
the axillary space and terminating at the lower borders of 
the latissimus dorsi and teres major muscles in the brachial 
(Figs. 90, 93). 

The axillary space, or axilla, through which the artery 
passes, is a conical-shaped cavity placed between the side 
of the chest above and the inner side of the arm. Its 
boundaries are formed by the pectoralis major and minor 
in front, the subscapulars, the latissimus dorsi and the 
teres major behind, the four upper ribs, intercostal mus- 
cles and part of the serratus magnus muscle on the inside, 
and the humerus, coraco-brachialis, and biceps muscles 
on the outside. This space contains important structures, 
in close relation; the axillary vessels and brachial plexus 
of nerves with their branches, also branches of the inter- 
costal nerves with lymphatic glands (ten or twelve in 
number), all held together by a quantity of fat and areolar 
tissue. A prolongation of the costo-coracoid membrane 
surrounds, to a greater or less extent, the vessels and nerves, 
forming a sheath for them. 

The course of the artery through this space varies ac- 
cording to the position of the arm. When the arm is 
placed in contact with the side of the chest, the artery is 
gently curved, the convexity looking upward and outward. 



124 



LIGATIONS. 



With the arm at right angles to the body, it passes in a 
direct line, and the arm being extended it assumes a curve, 

Fig. 93- 




Axillary Artery below Pectoralis Minor Muscle. 

1. Pectoralis major muscle drawn upward. 

2. Pectoralis minor. 

3. Latissimus dorsi and teres major muscles. 

4. Biceps muscle. 
5 Triceps muscle. 

6. Deep fascia of the arm. 

7. Axillary artery. 

8. Brachial artery. 

9. Coraeo-bracliialis muscle. 

10. Musculo-cutaneou.s nerve. 

11. Median nerve. 

12. Internal cutaneous nerve. 

13. Ulnar nerve. 

14. Axillary vein. 

15. Lymphatic gland. 

16. Subscapular and inferior thoracic vessels. 



THE AXILLARY ARTERY. I 25 

the convexity of which looks downward. It passes from 
the apex to the base of the axilla nearer the anterior than 
the posterior wall, and is divided into three parts by the 
pectoralis minor muscle, the first portion extending from 
the lower border of the first rib to the upper border of the 
muscle, the second lying behind it, and the third termi- 
nating at the insertion of the latissimus dorsi and teres 
major muscles. Ligation can be performed in either the 
first or third portion ; the second portion is quite inacces- 
sible, on account of its position behind the pectoralis 
minor muscle, and its relations complicated by being em- 
braced by the roots of the median nerve which arise from 
the inner and outer cord of the plexus, and unite either 
in front or on the outside of the artery. When selection 
is permitted, the third part is chosen as easier of access 
and freer from complications. 

Ligation in the First Portion. Course — From 
lower border of first rib to upper border of the pectoralis 
minor muscle. 

Surface marking — Lower border of clavicle. 

Relations at point of ligation : In front — Pectoralis major 
muscle, costo-coracoid membrane, cephalic vein. 

Behind — First intercostal space and muscle, second 
serration of serratus magnus muscle, posterior thoracic 
nerve. 

Inside — Axillary vein. 

Outside — Brachial plexus of nerves. 

Guides — Pectoralis major muscle, deeper, pectoralis 
minor muscle, and costo-coracoid membrane. 

Structures to be avoided — Superficially, cephalic vein 
and thoracico-acromialis artery; deeper, axillary vein 
and brachial plexus of nerves. 



126 LIGATIONS. 

Operation. — The arm and the shoulder being drawn 
back, an incision three inches in length, one-half of an 
inch below the clavicle and parallel to it, extending from 
the sternum to the edge of the deltoid muscle, should be 
made, dividing the skin. The superficial and deep fascia 
should be divided on the director, exposing the pectoralis 
major muscle. Divide the fibres of the clavicular portion of 
the muscle to the same extent as the external incision, and 
carefully incise the areolar tissue which lies below. Seek 
the upper border of the pectoralis minor muscle, and 
cautiously open the costo-coracoid membrane. Relax the 
pectoralis minor muscle by bringing the arm to the side, 
and separate with the grooved director the artery carefully 
from the vein and other structures, and pass the ligature 
needle from within outward, carefully avoiding the vein 

(Fig. 94)- 

The artery can be reached, if necessary, in the second 
part by extending this incision downward. 

Ligation in the Third Portion. Course — From the 
lower border of the pectoralis minor muscle to the lower 
borders of the latissimus dorsi and teres major muscles 
(Fig. 93). 

Surface markings — Borders of the axilla, head of the 
humerus, inner border of the coraco-brachialis muscle. 

Relations at point of ligation : In front — Skin, fascia, 
and pectoralis major muscle. 

Behind — Subscapularis, latissimus dorsi and teres major 
muscles, musculo-spiral and circumflex nerves. 

Inside — Axillary vein, ulnar and internal cutaneous 
nerves. 

Outside — Coraco-brachialis muscle, median and mus- 
culo-cutaneous nerves. 



THE AXILLARY ARTERY. 



127 



Guide — Coraco-brachialis muscle. 

Structures to be avoided — Axillary vein, median and 
ulnar nerves. 



Fig. 94. 




1. Axillary artery. 

2. Axillary vein. 

3. Brachial plexus of nerves. 

Operation. — Placing the arm at right angles to the 
body, make an incision two and one-half inches in length 
over the course of the artery, at the point of junction of 
the anterior and middle thirds of the axilla, dividing the 
skin. Divide the fascia carefully on the grooved director, 
separate the areolar tissue with the finger or handle of the 
knife, and seek the axillary vein to the inside and median 
nerve to the outside. Flex the arm so as to relax the 
vein and nerve, isolate the artery carefully, and pass the 
ligature needle from within outward (Fig. 95). Note a 
muscular slip from the latissimus dorsi muscle which occa- 
sionally crosses the artery at this point, which may mislead. 
The transverse direction of its fibres can be recognized. 



128 



LIGATIONS. 




1. Axillary vein. 

2. Axilla. 

3. Pneumogastric nerve. 

4. Ulnar nerve— drawn aside. 

5. Internal cutaneous nerve. 

6. Axillary artery. 

7. Inner border of coraco-brachialis muscle. 



The Brachial Artery. Surgical Anatomy. — This 
artery begins at the lower border of the tendons of the 
latissimus dorsi and teres major muscles, and passes down 
on the inner and anterior surface of the arm, terminating 
about one-half of an inch below the bend of the elbow in 
the radial and ulnar arteries (Fig. 96). A line drawn from 
the point of junction of the anterior and middle thirds of 
the axilla to a point midway between the condyles, will 
indicate its course. As it descends it winds around the 
bone, passing from the inner to the anterior surface. For 
the purposes of ligation, it may be divided conveniently 
into two parts, that lying above the point at which the 
median nerve crosses it, which may be designated as the 



THE BRACHIAL ARTERY. 



I29 



middle of the vessel, and 
that below this point. In 
the upper part, the nerve 
lies to the outer side of the 
artery in close contact; as 
it descends it passes very 
obliquely in front, and oc- 
casionally behind, and takes 
a position to the inner side. 
The artery also presents a 
number of peculiarities as to 
course, point of bifurcation, 
and muscular relations which 
should be considered by the 
student. 

Its course down the arm 
may be varied by a depart- 
ure from the inner border of 
the biceps muscle to the in- 
ner condyle of the humerus, 
and then to the bend of the 
elbow, passing through the 
pronator radii teres muscle. 

I, 2. The brachial artery. 

3. Coraco-brachialis muscle. 

4. Biceps muscle. 

5. Median nerve, crossing the artery. 

6. 7. Venae comites. 

8. Inferior profunda artery. 

9. Ulnar nerve. 

10. Bicipital fascia, beneath which the 
artery passes. 

II. Median basilic vein separated from 
the artery by bicipital fascia. 





I30 LIGATIONS. 

Irregularity with regard to the point of bifurcation is of 
rather frequent occurrence ; it occurs more frequently in 
the upper than in the middle or lower part of the arm — in 
three out of four cases it takes place as a high division of 
the radial, which arises from the inner surface of the bra- 
chial, and passes down the arm parallel with the main 
trunk to the elbow, where it crosses the artery to the out- 
side. In these cases, two large vessels would be found, 
which should be carefully examined, in order to decide 
to which one the ligature should be applied. 

Occasionally it is found that muscular layers passing 
between the coraco-brachialis and triceps muscles, and 
between the other muscles, have covered the artery for 
some distance in its course; these must be divided, in 
order to reach the vessel. 

Course — From the lower margin of the teres major 
muscle to one-half of *an inch below the bend of the 
elbow. A line drawn from the point of junction of the 
anterior and middle thirds of the axilla to a point midway 
between the condyles, will indicate its course.- 

Surface markings — Inner border of the coraco-brachi- 
alis and biceps muscles. 

General relations: In front — Skin and fascia, median 
nerve, and median basilic vein. 

Behind — Triceps, coraco-brachialis, and brachialis an- 
ticus muscles; musculo-spiral nerve, and superior profunda 
artery. 

Inside — Internal cutaneous, ulnar, and median nerves. 

Outside — Median nerve, coraco-brachialis and biceps 
muscles. 

Guides — Inner border of coraco-brachialis and biceps 
muscles. 



THE BRACHIAL ARTERY. I3I 

Structures to be avoided— -Median nerve, possibly ulnar 
nerve, and superior profunda artery; internal cutaneous 
nerve and basilic vein. 

Operation. — Above the point at which the median 
nerve crosses the artery. 

The arm being drawn from the side, and the hand supi- 
nated, an incision from two to three inches in length 
should be made along the inner border of the coraco- 
brachialis muscle, dividing the skin. The superficial and 
deep fasciae should be divided carefully on the director, 
care being taken to avoid the internal cutaneous nerve. 
The artery, accompanied by venae comites, will be found 
lying along the border of the coraco-brachialis muscle ; 
the internal cutaneous and ulnar nerves and basilic vein 
being to the inner, and the median to the outer side. 
Separate the venae comites, and pass the ligature-needle 
from within outward, avoiding the vein. 

Operation. — Below the point at which the median 
nerve crosses the artery. 

The arm being in the same position as in the operation 
just described, an incision from two to three inches is 
made directly over the inner border of the biceps muscle, 
dividing the skin. The superficial and deep fasciae are very 
carefully divided, in order to avoid the basilic vein, which 
at this point is superficial. The median nerve is now seen 
as a large white cord lying to the inside of the artery. 
Flex the arm so as to relax the biceps and median nerve, 
and separate the venae comites from the artery. Pass the 
ligature-needle from within outward (Fig. 97). 

In this operation the attention of the student is directed 
to the position of the artery, median nerve, and ulnar 
nerve, and their relation to each other. The artery, at 
this point, lies in very close contact with the border of 



132 



LIGATIONS. 



the biceps, the median nerve separated slightly to the 
inner side, and the ulnar nerve removed some distance 
from the median, and passing inward and backward. If 
the incision is made too far from the inner border of the 
biceps muscle, the ulnar nerve may be mistaken for the 
median, and thus confusion arise. This error can be 
avoided by keeping near to the border of the biceps 
muscle, and bearing in mind the order of relation from 
without inward, which is as follows: inner edge of biceps 
— artery in close contact; median nerve, slightly separated 
from artery; ulnar, separated to some distance from median 
nerve (Fig. 96). 

Fig. 97- 



* <* 




1 2 

1. Venae coraites. 

2. Median nerve. 

3. Brachial artery. 

4. Biceps muscle. 



The Brachial Artery at the Bend of the Elbow. 

Surgical Anatomy. — At this point the artery occupies 
a position beneath the tendon of the biceps in a triangular 
space formed by the supinator longus muscle externally, 
the pronator radii teres internally, the floor being formed 
by the brachialis anticus and supinator brevis muscles. 



THE BRACHIAL ARTERY. 



133 



Course — Obliquely across the bend of the elbow from 
within outward. 

Surface markings — Pronator radii teres and supinator 
longus. 

Relations: In front — Skin, fascia, median basilic vein, 
and bicipital fascia. 

Behind — Brachialis anticus muscle. 

Inside — Median nerve. 

Outside — Supinator longus muscle. 

Guide — Inner edge of tendon of biceps muscle. 

Structures to be avoided — Median basilic vein ; median 
nerve. 

Operation. — Make an incision two and a half inches 
in length along the inner edge of the biceps tendon, the 

Fig. 98. 




1. Brachial artery. 

2. Median nerve. 

3. Tendon of biceps muscle. 

4. Pronator radii teres muscle. 

5. Deep fascia. 



arm being extended and the hand supine, dividing the 
skin. Dividing the superficial fascia carefully, so as to 
avoid wounding the superficial veins, the bicipital fascia is 



134 



LIGATIONS. 



exposed. 



Fig. 99. 



Incise this and seek for the artery, surrounded 
bythevena? comites, beneath 
and lying between the tendon 
of the biceps muscle on the 
outside and the median nerve 
on the inside. Pass the liga- 
ture-needle from the median 
nerve (Fig. 98). 

The Radial Artery. Sur- 
gical Anatomy. — The radial 
artery, the smaller of the two 
vessels into which the bra- 
chial divides, passes from its 

1. Brachial artery. 

2. 2. Radial and ulnar arteries at point 

of bifurcation. 

5. dinar artery, middle third. 

4. Ulnar artery, lower third. 
.">. Superficial palmar arch. 

6. Radial artery, middle third. 

7. Radial artery, lower third. 

5. Median nerve. 

9. Median basilic vein. 

10. Bicipital fascia. 

11. Median nerve crossing ulnar ar- 
tery. 

12. Ulnar nerve. 

13. Tendon and muscle of flexor carpi 
ulnarls. 

14. Inner tendon o( the flexor sublimis 
digitorum. 

15. Supinator Ion gus muscle. 

16. Pronator radii teres muscle cut 
through. 

17. Superficial flexor muscles cut 
through, showing ulnar artery and 
median nerve. 

IS. Beginning ol' tendon of supinator 
longus muscle. 

19. Radial nerve. 

20. Vena' comites. 




Tlie Radial aud Ulnar Arteries. 



THE RADIAL ARTERY. 1 35 

point of origin, opposite the coronoid process of the ulna, 
downward and outward along the radial side of the fore- 
arm to the wrist. In its course it passes from the inside 
of the radius above to the front of the bone below. A 
ligature may be applied at any part of its course in the 
tipper, middle, or lower third (Fig. 99). 

Course — A line drawn from the middle of the bend of 
the elbow to the front of the styloid process will represent 
its course. 

Surface marking — Inner border of the muscle and ten- 
don of the supinator longus. 

General relations : In front — Skin, superficial and deep 
fasciae, supinator longus muscle. 

Behind — Tendon of biceps muscle, supinator brevis, 
pronator radii teres, flexor sublimis digitorum, flexor lon- 
gus pollicis, pronator quadratus muscles, and the radius. 

Inside — Pronator radii teres muscle, flexor carpi radialis 
muscle, and tendon. 

Outside — Supinator muscle and tendon. 

Guide — Supinator longus muscle and tendon. 

Structures to be avoided — Median vein and radial nerve. 

Operation: /;/ the upper third. — An incision, from two 
to three inches in length, dividing the skin and carefully 
avoiding the median vein, is made from the bend of the 
elbow obliquely downward and outward in the groove 
which marks the line of separation between the supinator 
longus and pronator radii teres muscles. The superficial 
and deep fasciae are divided on the director. Flexing the 
arm slightly, so as to relax the muscles, the supinator 
longus is drawn aside, and the artery, in its sheath with the 
venae comites, will be exposed, the radial nerve lying to 



I3 6 



LIGATIONS. 



the outside. Separating the venae comites, the ligature 
needle is passed from without inward (Fig. ioo). 

Fig. ioo. 




1. Supinator longus muscle. 

2. Eadial artery. 



In the middle third. — The artery can be exposed by an 
incision two inches in length along the inner border of 
the supinator longus muscle, dividing the skin. The 

fasciae being divid- 
Fig. 101. ed, the artery is 

found, with the ra- 
dial nerve in close 
contact on the out- 
side. Pass the liga- 
ture needle from the 
nerve. 

In the lower third. 
— At this point the 
artery lies super- 
ficial between the 
tendons of the supi- 
nator longus and flexor carpi radialis, the nerve being 




1. Deep fascia. 

2. 4. Venae comites. 

3. Artery. 



THE RADIAL ARTERY 



137 



some distance to the outside, leaving the artery about 
three inches above the wrist. Fix the position of the 
tendon of the flexor carpi radialis muscle by manipulat- 
ing the hand, and make an incision one inch and a half 
along its external border, dividing the skin. Divide the 
fasciae on the director, and thus expose the sheath of the 
vessel. Open the sheath, separate 
the artery from the venae comites, Fig. 102. 

and pass the ligature needle from 
without inward (Fig. 10 1). 



On the Outer Side of the 

Wrist. Surgical Anatomy. — The 
artery, as it crosses to the outer side 
of the wrist to pass into the hand, 
lies beneath the extensor tendons of 
the thumb, in a space known as 
the "snuff-box" (Fig. 102). Here 
it can be ligated by making an 
incision, which divides the skin, 
one inch and a quarter in length, 
beginning opposite the styloid pro- 
cess of the radius and terminating 
at the first interosseous space. 
Dividing the fasciae on the director, 
seek the tendon of the extensor 
secundi internodii pollicis muscle, 
which crosses the artery just before 
it passes into the palm of the hand, 
and furnishes a guide to the vessel. 
Apply the ligature to the artery on 
the ulnar side of the tendon, avoid- 

12* 




Radial Artery on the outer 
side of the Wrist. 

1. Posterior annular liga- 
ment of the carpus. 

2. Tendon of extensor ossis 
metacarpi pollicis. 

3. Tendon of extensor pri- 
mi internodii pollicis. 

4. Tendon of the extensor 
secundi internodii pollicis 

5. Radial artery. 



I38 LIGATIONS. 

ing the veins and a small branch of the musculo-cutaneous 
nerve which accompanies it. 

The Ulnar Artery. Surgical Anatomy.— This vessel, 
the larger of the two terminal branches of the brachial 
artery, begins at the point of bifurcation opposite the 
coronoid process of the ulna, and crosses obliquely to the 
inner side of the forearm, which it reaches about the 
middle, then descends along the ulnar border to the wrist, 
terminating in the superficial palmar arch. A line drawn 
from the internal condyle of the humerus to the outer side 
of the pisiform bone, will indicate its course in the lower 
half. Ligation in the upper portion is rarely performed, 
owing to the position of the vessel beneath the superficial 
flexor muscles, which must be divided in order to apply 
the ligature. In the middle part it is slightly covered by 
the tendons of the flexor carpi ulnaris and the inner ten- 
don of the flexor sublimis digitorum. In the lower part 
it is superficial. The median nerve crosses it obliquely 
just below its point of origin, while the ulnar nerve comes 
into close relation with it at the lower part of the upper 
half (Fig. 99). 

Course — From the bend of the elbow to the radial side 
of the pisifoim bone. 

Surface marking — Muscle and tendon of the flexor 
carpi ulnaris. 

General relations : In front : Upper half— Superficial 
flexor muscles and median nerve. 

Lower /za^— Superficial and deep fasciae. 

Behind — Brachialis anticus and flexor profundus digito- 
rum muscles. 

Inside — Flexor carpi ulnaris muscle and, in lower two- 
thirds, ulnar nerve. 



THE ULNAR ARTERY. 



139 



Outside — Muscle and tendons of the flexor sublimis 
digitorum. 

Guide — Muscle and tendon of the flexor carpi ulnaris. 

Structures to be avoided — Ulnar nerve and venae comites 
in upper half; median nerve. 

Operation : In upper half. — An incision should be made 
starting two and one-half inches below the internal con- 
dyle of the humerus, and one-quarter of the width of the 
arm from the inner edge, extending downward to the 
extent of three inches, dividing the skin. The fasciae 
being divided, seek the white, pearly aponeurotic line 
marking the septum between the flexor carpi ulnaris mus- 
cle on the inside, and the flexor sublimis digitorum on the 
outside. Incise this septum to the same extent as the inci- 




1. Flexor sublimis muscle. 

2. Uluar nerve. 

3. Plexor profundus muscle. 

4. Vense comite-. 

5. Ulnar artery. 



sion through 



the skin and fasciae. Flex the arm, and 
separate with the finger the superficial muscles from the 
flexor profundus digitorum. Seek the artery lying on this 



140 



LIGATIONS. 



muscle with the ulnar nerve to the inside. Pass the liga- 
ture-needle from the nerve (Fig. 103). 

In ligating the vessel at this point the student should 
take especial care in seeking for the septum which sepa- 
rates the flexor carpi ulnaris from the flexor sublimis digi- 
torum muscle, and which is to be divided in preference to 
the muscular substance. It will be recognized as a white, 
glistening membrane, the fibres of which are parallel with 
the fibres of the muscles. 

In middle of the forearm. — The artery can be reached 
by an incision three inches in length along the external 
border of the flexor carpi ulnaris, dividing the skin. The 
fasciae being divided, the flexor carpi ulnaris and the inner 
tendon of the flexor sublimis digitorum should be sepa- 
rated, exposing the artery with the ulnar nerve to the 




^JJjJjJJUU^i^M 



1. Flexor carpi ulnaris muscle. 

2. Venae comites. 

3. The integuments. 

4. Ulnar artery. 

5. Deep fascia. 



inside in close relation. Pass the ligature-needle from 
the nerve, avoiding the venae comites. 



THE ABDOMINAL AORTA. 141 

In lower half. — An incision two inches in length is made 
along the outer edge of the tendon of the flexor carpi 
ulnar is muscle three-quarters of an inch from the ulnar 
border of the limb, dividing the skin. Divide the fasciae 
on the director, and, slightly flexing the hand, seek the 
artery covered by the tendon of the flexor carpi ulnaris 
and inner tendon of the flexor sublimis digitorum muscle. 
Separate the venae comites, and pass the ligature from 
within outward (Fig. 104). 

In this operation the student is cautioned against mak- 
ing the incision too near the ulnar border of the limb. 

The Abdominal Aorta. Surgical Anatomy. — The 
abdominal portion of the aorta is the continuation of the 
thoracic portion, beginning at the opening in the dia- 
phragm opposite the body of the last dorsal vertebra, and 
descending on the left side of the vertebrae, terminates on 
the left side of the fourth lumbar vertebra in the two com- 
mon iliac arteries. Between the point of origin of the 
inferior mesenteric artery, a large branch, and the bifurca- 
tion of the aorta into the common iliac arteries, there are 
given off from the posterior surface several small branches, 
four lumbar from each side, and the sacra media. This 
portion of the vessel, therefore, presents itself as best 
adapted for the application of the ligature, as well on this 
account as on account of its position rendering it easier 
of access. 

Course — From the front of the body of the last dorsal 
vertebra downward on the left side of the vertebral col- 
umn to the left side of the body of the fourth lumbar 
vertebra at the point of bifurcation. 

Surface marking — The linea alba. 



I4 2 LIGATIONS. 

Relations at point of ligation: In front — The structures 
forming the abdominal wall, transverse colon, omentum, 
and mesentery; convolutions of the small intestines, peri- 
toneum. 

Behind — Left lumbar veins and vertebrae. 

Right side — Inferior vena cava. 

Left side — Sympathetic nerve. 

Guide — Vertebral column. 

Structures to be avoided — Inferior vena cava, sympathetic 
nerve. 

Operation. — The vessel can be reached By two methods 
of operation. 

i. By an incision three inches in length through the 
skin, beginning one and a half inch above umbilicus in 
the linea alba. Carrying the incision around umbilicus, 
divide the structures on the director until the peritoneum 
is reached ; incise this on the director, thus opening the 
abdominal cavity. Raise the omentum, and push the in- 
testines to the right side. Seek the aorta on the left side 
of the lumbar vertebrae, and carefully tear through the 
peritoneum covering the vessel. Pass the ligature from 
the right to the left, avoiding the vena cava. 

2. An incision should be made on the left side of the 
body from the end of the eleventh rib to the crest of the 
ilium, dividing the common integuments. The layers of 
muscles, external and internal, oblique and transversalis, 
and transversalis fascia, should be carefully divided on 
the director. Cautiously push off the posterior layer of 
the peritoneum until the aorta is uncovered, and pass the 
ligature as in the first method. 

The advantage this method has over the first, is in pre- 
serving the integrity of the peritoneum. On the other 



THE COMMON ILIAC ARTERY. 



143 



hand, the operation by the second plan involves the 
wounding of the muscular structures, and separation, to 
some extent, of the peritoneum from the underlying struc- 
tures. 



The Common Iliac Artery. Surgical Anatomy. — 
The common iliac arteries, terminal branches of the aorta, 
begin at the point of bifurcation on the left side of the 
body of the fourth 

lumbar vertebra, and Fig. 105. 

pass downward and 
outward to the margin / 
of the pelvis. Oppo- 



1. Section of the muscles of 
the abdomen at their insertion 
into crest of the ilium. 

2. Superior spinous process 
of the ilium. 

3. Fascia lata of the thigh. 

4. Psoas muscle. 

5. Iliacus internus muscle. 

6. Aorta. 

7. Eight common iliac ar- 
tery. 

8. External iliac artery. 

9. Internal iliac artery. 

10. Iliac vein. 

11. Inferior vena cava. 

12. Anterior crural nerve. 

13. Lymphatic glands. 

14. Spermatic vessels. 

15. Circumflex iliac artery. 

16. The ureter. 

17. The epigastric artery. 




The Common, 



External, and Internal II 
Arteries. 



site the intervertebral substance, between the last lumbar 
vertebra and the sacrum, they divide into the external and 
internal iliac arteries. The point of bifurcation of the 



144 LIGATIONS. 

aorta corresponds to a point to the left of the umbilicus, 
and on a level with a line passing between the highest 
points on the crests of the ilia (Fig. 105). 

It is to be noted that these vessels lie beneath the peri- 
toneum, and that the relation of the vein on the right and 
left side differs, being behind and exteimal on the right 
side, and behind and internal on the left. High up, the 
left vein passes behind the right common iliac artery to 
join the right vein in forming the inferior vena cava. 
Peculiarities with regard to point of origin, point of divi- 
sion, and relative length are frequently observed, and 
should be borne in mind. * 

Course — From bifurcation of aorta on left side of body 
of fourth lumbar vertebra, downward and outward to 
opposite the intervertebral substance between last lumbar 
vertebra and sacrum. A line drawn from the left side of 
the umbilicus to the middle of Poupart's ligament indi- 
cates the course. Length of the vessel, two inches. 

Relations at point of ligation : Right common iliac artery : 
In front — Peritoneum, ileum, branches of sympathetic 
nerve; at the point of bifurcation into the external and 
internal iliac arteries, it is crossed by the ureter. 

Behind — The two common iliac veins. 

Outside — Inferior vena cava, right common iliac vein ; 
psoas magnus muscle. 

Left common iliac artery: In front — Peritoneum, 
branches of sympathetic nerve, rectum, superior hemor- 
rhoidal artery ; at bifurcation, crossed by left ureter. 

Behind — Left common iliac vein. 

Inside — Left common iliac vein. 

Outside — Psoas magnus muscle. 

Guide — Sacro-iliac articulation. 



THE EXTERNAL ILIAC ARTERY. 1 45 

Structures to be avoided — Common iliac veins, ureters, 
sympathetic nerve, inferior vena cava, peritoneum. 

Operation. — An incision, in a direction outward to the 
anterior superior spine of the ilium, from six to eight 
inches in length, should be made two inches above and 
parallel to Poupart's ligament, beginning at the junction 
of the inner and middle third of the space between the 
symphysis pubis and the anterior superior spine of the 
ilium, dividing the skin. The superficial and deep fasciae, 
tendon of the external oblique muscle, the internal oblique 
and transversalis muscles are to be carefully divided on 
the director, layer after layer, until the transversalis fascia 
is exposed. The edges of the wound should be separated 
by spatulas, the transversalis fascia gently raised and 
scratched through, making an opening, into which the 
point of the director can be introduced. Making sure, 
by careful examination, that the director is between the 
fascia and the peritoneum, and not beneath the latter, the 
fascia should be divided. The peritoneum is now gently 
pushed off to a sufficient extent to enable the artery to be 
brought into view at the sacro-iliac junction. Opening 
carefully, with the finger nail or with the point of the 
director, the sheath of the vessel, and separating the vein 
from the artery, the ligature is to be passed from the latter. 

The External Iliac Artery. Surgical Anatomy. — 
The external iliac artery is the larger of the two terminal 
branches of the common iliac, and passes from the point 
of bifurcation obliquely downward and outward along the 
inner border of the psoas magnus muscle to the crural 
arch. A line drawn from a point to the left of the um- 
bilicus, to a point midway between the anterior superior 
13 



146 



LIGATIONS. 



spinous process and the symphysis pubis, will indicate its 
course (Fig. 105). 

Course — Obliquely downward and outward across the 
pelvic cavity to the crural arch. 

Relations at the point of ligation : In front — Peritoneum, 
intestines, iliac fascia, spermatic vessels, genito -crural 
nerve, circumflex iliac vein, lymphatic vessels and glands. 

Behind — External 
Fi S- Io6 - iliac vein. 

Inside — External 
iliac vein and the vas 
deferens. 

Outside — Psoas mag- 

nus muscle, iliac fascia. 

Guide — Inner border 

of the psoas magnus 

muscle. 

Structures to be avoid- 
ed — External iliac vein, 
genito - crural nerve, 
peritoneum. 

Operation. — This 
artery can be exposed 
by the same plan of 
operation as that em- 
ployed in ligation of 
the common iliac artery (page 145). The incision need 
be but four inches in length, and not so far removed 
from the line of Poupart's ligament (Fig. 106). 




1. The internal oblique and transversali 
muscles. 

2. The external iliac artery. 

3. The external oblique muscle. 

4. The peritoneum. 



The Internal Iliac Artery. Surgical Anatomy. — 
The internal iliac artery, the smaller of the terminal 



THE INTERNAL ILIAC ARTERY. 1 47 

branches of the common iliac, is a short branch measur- 
ing about an inch and a half in length (Fig. 105). It 
presents peculiarities, as to length and point of division, 
which should be noted. 

Course — From the point of bifurcation of the common 
iliacs, downward to the upper margin of the great sacro- 
sciatic foramen. 

General relations : In front — Peritoneum, ureter. 

Behind — Internal iliac vein, lumbo-sacral nerve, pyri- 
formis muscle. 

Outside — Psoas magnus muscle. 

Guide — Inner border of the psoas magnus muscle. 

Structures to be avoided — Internal iliac vein and ureter, 
peritoneum. 

Operation.— This vessel can be surrounded by a liga- 
ture by the same method as that described for tying the 
external iliac artery (Fig. 106). 

In performing operations for the ligation of the iliac 
arteries, careful attention should be given to the relations 
of the large venous trunks which accompany them. These 
vessels lie in close contact with the arteries, their walls are 
delicate and thin, and they receive numerous branches 
from the different parts of the pelvic cavity. Great care 
should be exercised in using instruments to displace them 
or to separate them from the arteries. The position of 
the ureters should also be carefully considered. Being 
closely united to the peritoneum, they are usually lifted 
with that structure when it is detached to expose the 
vessels. In persons of advanced age, the peritoneum is 
frequently found quite adherent to the underlying tissues, 
and therefore difficult to separate. In these cases, unless 
great caution be observed, this membrane may be lacerated. 



I48 LIGATIONS. 

The Gluteal Artery. Surgical Anatomy. — The 
.gluteal artery, the largest branch of the internal iliac, is 
given off from the posterior trunk, and passes out of the 
pelvic cavity through the great sacro-sciatic foramen above 
the upper border of the pyriformis muscle. 

Course — A line drawn from the posterior superior spine 
of the ilium to the top of the great trochanter, indicates 
the course of the artery after its emergence from the pelvic 
cavity. 

General relations : Outside — Skin, superficial and deep 
fasciae, glutaeus maximus muscle. 

Inside — Glutaeus minimus muscle. 

Above — Glutaeus medius muscle. 

Below — Pyriformis muscle. 

Guides — Pyriformis and glutaeus medius muscles. 

Structures to be avoided — Gluteal vein and superior 
gluteal nerve. 

Operation. — The patient being placed on his abdomen, 
an incision, five inches in length, is made over the course 
of the artery, dividing the skin. The superficial and deep 
fasciae are divided on the director, exposing the glutaeus 
maximus muscle. The fibres of this muscle should be 
separated, and the artery sought for as it emerges from 
the pelvic cavity above the upper border of the pyriformis 
muscle, and the ligature applied, carefully avoiding the 
veins and nerve. 

The Sciatic Artery. Surgical Anatomy. — The 
sciatic artery is the larger of the two terminal branches of 
the anterior trunk of the internal iliac, and escapes from 
the pelvic cavity through the lower part of the great sacro- 
sciatic foramen. 



THE INTERNAL PUDIC ARTERY. 1 49 

Course — After emerging from the pelvic cavity through 
the lower part of the great sacro-sciatic foramen between 
the pyriformis and coccygeus muscles, it passes downward 
in the interval between the trochanter major and tuber- 
osity of the ischium. The point of exit from the pelvic 
cavity is indicated by the centre of a line drawn from the 
posterior superior spinous process of the ilium to the 
tuberosity of the ischium. 

Relations : Outside — Skin, superficial and deep fasciae, 
and glutaeus maximus muscle. 

Inside— Gemellus superior and obturator internus mus- 
cles. 

Above — Pyriformis muscle. 

Below — Coccygeus muscle. 

Guide — Coccygeus muscle, and lower border of the 
pyriformis muscle. 

Structures to be avoided — Internal pudic artery, sciatic 
nerve and vein. 

Operation. — The patient being placed upon the abdo- 
men, an incision three inches in length is made over the 
point of exit of the artery from the pelvic cavity, in the 
line given to indicate this point, dividing the skin. The 
superficial and deep fasciae should be divided, exposing 
the fibres of the glutaeus maximus muscle. Separate the 
fibres of this muscle, and seek the artery as it appears 
between the coccygeus and pyriformis muscles. Pass the 
ligature, carefully avoiding the nerve and vein. 

The Internal Pudic Artery. Surgical Anatomy. — ■ 
This artery is the smaller of the two terminal branches of 
the anterior trunk of the internal iliac. As it escapes 
from the pelvic cavity by the same opening as the sciatic 

13* 



i5° 



LIGATIONS. 



artery, its course and relations at the point of ligation are 
essentially the same, and it may be secured by a similar 
plan of operation. 



Fig. 107. 




The Femoral Artery. 



The Femoral Ar- 
tery. Surgical Anat- 
omy. — The femoral ar- 
tery is the continuation 
of the external iliac, 
and passes downward 
on the anterior and in- 
ner aspect of the thigh 
from the crural arch to 
the junction of the mid- 
dle with the lower third 
of the thigh, where it 
enters an opening in 
the adductor magnus 
muscle and becomes 

1. Poupart's ligament. 

2. Aponeurosis forming Hun- 
ter's canal. 

3. Anterior crural nerve. 

4. Femoral artery. 

5. Femoral vein. 

6. Long saphenous nerve. 

7. 7. Sartorius muscle, drawn 
to the outside. 

8. Internal saphenous vein. 

9. Profunda femoris artery. 

10. Branch of anterior crural 
nerve, lying in front of the fem- 
oral sheath. 

11. Another branch which 
passes across the vessels to 
join the internal saphenous 
vein. 

12. 12. Musculo- cutaneous 
branches. 



THE FEMORAL ARTERY. 151 

the popliteal (Fig. 107). The upper third of the vessel 
is superficial, and occupies a triangular space called 
"Scarpa's triangle." This triangle corresponds to- the 
depression immediately below the fold of the groin, and 
is bounded by the sartorius muscle on the outside, the 
adductor longus muscle on the inside, and Poupart's liga- 
ment above. The floor is formed by the iliacus, psoas, 
pectineus, adductor longus, and a part of the adductor 
brevis muscles, passing in order from without inward. 

The femoral vessels bisect this triangle as they pass 
from the middle of the base to the apex. Above, the 
artery lies on the inner border of the psoas magnus mus- 
cle, which separates it from the capsular ligament of the 
hip-joint. The artery and vein are inclosed in a strong 
fibrous sheath, the crural sheath, formed by the trans- 
versalis and iliac fasciae — the artery, to the outside, and 
the vein, to the inside, separated by a septum. 

The anterior crural nerve lies to the outside of the 
common sheath, to the distance of about one-half of an 
inch. The femoral vein above lies to the inner side of 
the artery; a short distance below the origin of the pro- 
funda femoris it passes behind the artery, and in the lower 
third it is placed on the outside. 

The course the vein takes should be remembered, and 
its relations to the artery at the various parts of its course 
— inside, behind, and outside, in order, from above 
downward. 

The internal saphenous nerve, the largest branch of the 
anterior crural, comes into immediate relation with the 
artery about the middle third, as it passes, beneath the 
sartorius muscle ; as it descends it gradually gets in front of 
the artery, crossing it as it enters Hunter's canal, and pass- 



I 



152 LIGATIONS. 

ing to the inside of the thigh. The nerve acts as a guide 
to the vessel as it passes into this canal. 

Hunter's canal,- from one to two inches in length, is 
described as being formed by a dense fibrous aponeurosis, 
extending from the tendons of the adductors longus and 
magnus downward and inward to unite with the tendinous 
origin of the vastus interims muscle. It is triangular in 
shape, and bounded externally by the vastus internus, and 
internally by the adductor longus and adductor magnus 
muscles. 

As the internal saphenous vein passes up the thigh to 
join the femoral, through the saphenous opening, it has 
an important relation to the points at which the incisions 
are made for exposing the artery in its lower and middle 
thirds, lying almost directly in the line of the incisions. 
The position of the vein should always be ascertained by 
making pressure over its course above, and it should be 
drawn to the inside while the incision is being made. In 
its course it receives numerous branches, which join it from 
the outer and inner surfaces of the thigh. 

As ligation of the artery above the origin of the pro- 
funda femoris is not advised, it is important to determine 
the point at which this vessel is given off. Its normal 
point of origin is stated to be from one to two inches 
below Poupart's ligament, and from the outer and back 
part of the artery. Anomalies, with regard to its point of 
origin, are noted as occasionally occurring, the vessel 
being given off at or just below Poupart's ligament, and, 
in one instance, four inches below. It should also be 
remembered that occasionally the artery divides into two 
trunks below the origin of the profunda, and reunites be- 
fore entering Hunter's canal. 



THE FEMORAL ARTERY. I 53 

A rare anomaly with regard to the position of the 
femoral artery is noted, in which the vessel occurred as a 
branch of the internal iliac artery, passed out of the pelvic 
cavity through the great sacro-sciatic foramen, and de- 
scended the thigh in its posterior aspect in connection with 
the great sciatic nerve. In the living subject, absence of 
pulsation at the crural arch would suggest the existence 
of such an anomaly. 

Course — From a point midway between the anterior 
superior spinous process of the ilium and the symphysis 
pubis, down the front and inner side of the thigh, termi- 
nating at the opening in the adductor magnus muscle, this 
opening being at the junction of the middle with the lower 
third of the thigh. A line drawn from the point midway 
between the anterior superior spinous process of the ilium 
and the symphysis pubis to the inner side of the inner con- 
dyle of the femur, will indicate its course. 

Surface marking — Inner edge of the sartorius muscle. 

General relations : In front — Skin, superficial and deep 
fasciae, and sartorius muscle. 

Behind — Psoas, pectineus, adductor longus and tendon 
of adductor magnus muscles, femoral vein. 

Inside — Femoral vein. 

Outside — Anterior crural and internal saphenous nerves, 
vastus internus muscle. 

Guide — Inner border of the sartorius muscle. 

Structures to be avoided — Internal saphenous and femoral 
veins, internal saphenous nerve. 

Common sheath — Including artery and vein. 

Operation. — The common femoral, above the pro- 
funda femoris. 

An incision two inches in length is made over the course 



154 



LIGATIONS. 



of the artery, beginning at a point midway between the 
anterior superior spinous process of the ilium and symphy- 
sis pubis, dividing the skin. The fasciae are carefully 
divided on the director, and the sheath of the vessels ex- 
posed. Opening 
Fig. 108. this to a slight 

extent, the vein 
is drawn inward, 
and the ligature 
needle passed 
from within out- 
ward (Fig. 108). 
In the opera- 
tion at this point, 
which is not ad- 
vised, owing to 
the number of 
branches 'here 
given off from 
the artery, care 
should be taken 
to pass the liga- 
ture above the origin of the profunda femoris, and not 
immediately below it. This can be accomplished by 
bringing into view Poupart's ligament, and applying the 
ligature from three-quarters to one inch below. The fold 
of the groin should not be taken as a guide to the position 
of Poupart's ligament, as in those who are corpulent the 
fold is below the ligament, and not on a line with it. 

Operation. — The superficial femoral artery at the apex 

of Scarpa's triangle, four inches below Poupart's ligament. 

To apply the ligature to the artery at this point of its 




The doep fascia. 
The femoral artery. 
The femoral vein. 



THE FEMORAL ARTERY. 



155 



course, the leg should be flexed upon the thigh, and the 
thigh abducted and rotated outward, the position of the 
internal saphenous vein ascertained by pressure applied 
above, and an incision three inches in length made along 
the inner border of the sartorius muscle, dividing the skin. 
The superficial and deep fasciae are now divided on the 
director, and the border of the sartorius muscle sought. 
This muscle can be 

distinguished by the Fi S- io 9- 

direction its fibres 
take obliquely 
downward and in- 
ward. Drawing 
the muscle out- 
ward, the sheath of 
the vessels is ex- 
posed, and should 
be opened to a 
slight extent. The 
ligature needle 
should be passed 
carefully from with- 
in outward, avoid- 
ing the vein (Fig. 
109). 

In performing 
this operation, it 

should be remembered that the femoral vein lies at this 
point beneath the artery, and in close contact. Great 
care is to be exercised, therefore, in passing the ligature 
needle, in order that the vein should not be injured, and 
that it be not included in the ligature. 




1. The deep fascia. 

2. The sartorius muscle drawn aside. 

3. The femoral artery. 

4. The femoral vein. 



156 LIGATIONS. 

Operation. — The superficial femoral artery in Hunter's 
canal. 

The limb being flexed and rotated outward, an incision 
from three to four inches in length, dividing the skin, is 
made in the course of the artery, over the point of junc- 
tion of the middle and lower third of the thigh. The 
superficial and deep fasciae are to be divided on the director, 
and the outer border of the sartorius muscle sought for. 
This muscle is drawn inward, exposing Hunter's canal, 
in which are placed the artery, vein, and the long saphe- 
nous nerve. The canal should be opened carefully on the 
director, and, nicking the sheath slightly, the ligature 
needle should be passed from without inward, avoiding 
the vein and long saphenous nerve. 

Attention is directed to the position of the artery, vein,, 
and long saphenous nerve as they lie in Hunter's canal. 
At this point the vein is to the outside; the nerve, while 
it is in the canal, and before it reaches the opening in the 
adductor magnus, quits the outside of the artery and passes 
across to the inner side of the thigh. A number of 
branches of the nerve are distributed to the vastus internus 
muscle, and may be mistaken for the internal saphenous. 
They may be distinguished by examining carefully their 
relations to the artery, being placed more externally than 
the saphenous nerve. The vastus internus muscle can be 
recognized by the direction of its fibres, which pass from 
above downward and outward. 

The Popliteal Artery. Surgical Anatomy. — The 
popliteal artery, the continuation of the femoral, begins at 
the opening in the adductor magnus muscle, and, passing 
obliquely downward and outward, terminates at the lower 



THE POPLITEAL ARTERY. 



157 



border of the popliteal muscle, in the anterior and poste- 



rior tibial arteries (Fig. 110). 
close contact with the posterior 
ligament of the knee-joint (Fig. 
174), occupying a lozenge- 
shaped space, called the pop- 
liteal space, which is placed be- 
tween the lower third of the 
thigh and the upper fifth of the 
leg. The popliteal space is 
bounded above the knee-joint, 
externally, by the biceps mus- 
cle, and below the joint by the 



External saphenous vein. 
Popliteal nerve. 
Peroneal nerve. 
External saphenous nerve. 
Branch of the peroneal nerve. 
6. Deep fascia. 
Semimembranosus muscle. 
Biceps muscle. 

9. Cutaneous vessels and nervi 
. Internal saphenous vein. 
. Popliteal artery. 
. Popliteal vein. 



Iii its course, it lies in 




Surgical Anatomy — Popliteal 
Artery. 



plantaris and external head of the gastrocnemius muscles; 
above the joint, internally, by the semimembranosus, semi- 
tendinosus, gracilis, and sartorius muscles; below the joint, 
internally, by the inner head of the gastrocnemius muscle. 
The floor is formed, from above downward, by the lower 
part of the posterior surface of the shaft of the femur, the 
posterior ligament of the knee-joint, the superior extremity 
of the tibia, and the fascia covering the popliteus muscle. 
The fascia lata (deep fascia) covers in the space, forming 
14 



158 LIGATIONS. 

a firm protective membrane to the structures contained in 
it. The important bloodvessels and nerves are placed in 
the following order, from without inward : The internal 
popliteal nerve, the larger of the two terminal branches 
of the great sciatic is most superficial, being separated from 
the vessels which lie beneath by a thick layer of fat. In 
the upper part of the space it occupies a position to the 
outside of the artery, crossing it at the middle and passing 
to the inside as it leaves the space. 

The popliteal vein, formed by the union of the venae 
comites of the anterior and posterior tibial arteries, lies 
beneath the nerve. Occasionally the union does not take 
place below, and the artery is then embraced by the two 
veins which are in close contact with it. In the lower 
part of the space it is placed on the inner side of the artery, 
in the middle it is superficial to it, and crosses it to take a 
position on its outer side. 

Beneath the nerve and the vein, the artery is placed in 
close contact with the posterior ligament of the joint. 
Numerous branches are given off from the artery and 
nerve to the joint and surrounding muscular structures, 
and the vein receives the external or short saphenous and 
branches from the joint and muscles. 

The application of a ligature to the popliteal artery, 
owing to the relations it has to the surrounding structures, 
as well as the numerous branches arising from it at right 
angles, is, necessarily, an operation in which the greatest 
care should be exercised. Ligation may be performed in 
the upper or lower part of its course. The middle portion 
should not be interfered with, owing to its deep position, 
its proximity to the knee-joint, and its close relations with 
the vein and nerve. 



THE POPLITEAL ARTERY. 1 59 

Course — From the opening in the adductor magnus 
muscle, obliquely downward and outward to the lower 
border of the popliteus muscle, traversing the middle of 
the popliteal space. 

Surface markings — Borders of the muscles which form 
the boundaries of the popliteal space. 

General relations : In front — Above, the inner side of 
the femur; in the middle, the posterior ligament of the 
joint; and, below, the popliteal fascia. 

Behind — The popliteal vein, layer of fat, internal pop- 
liteal nerve, fascia lata (deep fascia), superficial fascia, 
and skin. 

Inside — Semimembranosus and inner head of the gas- 
trocnemius muscles. 

Outside — Biceps and outer head of the gastrocnemius 
muscles. 

Guides — Above, the border of the semimembranosus 
muscle; below, the heads of the gastrocnemius muscle. 

Structures to be avoided — External saphenous vein, 
popliteal vein, and internal popliteal nerve, with their 
branches. 

Operation: In upper third. — The patient being placed 
in the prone position, with the limb extended, an incision 
three inches in length should be made along the posterior 
margin of the semimembranosus muscle, dividing the skin. 
The superficial and deep fasciae are next divided carefully 
on the director, bringing into view the border of the semi- 
membranosus muscle, which should be drawn inward, 
exposing the internal popliteal nerve lying to the outside. 
Separating carefully the layer of fat, which is usually found 
between the nerve and the vein and artery, the latter is 
sought for beneath the vein, and somewhat to its inner side. 



i6o 



LIGATIONS. 



Fig. 



Detaching cautiously the artery from the vein, the ligature 
needle is passed from without inward (Fig. in). 

In the lower third, between the heads of the gastrocnemius 
muscle. — An incision, three inches 
in length, should be made in the 
middle line, beginning opposite 
the bend of the knee-joint, divid- 
ing the skin. The superficial 
and deepf?*ciae should be divided 
on the director, care being taken 
to avoid the external or short 
saphenous vein, which perforates 
the deep fascia in the lower part 
of the popliteal space to join the 
vense comites. Superficial 
branches of the internal popliteal 

1. The popliteal artery. 

2. The skin. 

3. The superficial fascia. 

4. The fascia lata (deep fascia). 

5. The internal popliteal Derve. 

6. The biceps muscle. 

7. The popliteal vein. 




nerve are also to be avoided in dividing the fasciae. After 
the division of the deep fascia, the nerve, vein, and artery 
are found, placed in the order named from without inward, 
between the heads of the gastrocnemius muscle. Flexing 
the leg, so as to relax the heads of the gastrocnemius, 
the nerve and vein are cautiously separated from the artery, 
and the ligature needle is passed from without inward. 



The Anterior Tibial Artery. Surgical Anatomy. — 
At the lower border of the popliteus muscle the anterior 



THE ANTERIOR TIBIAL ARTERY. 



161 



tibial artery is given 
off from the pop- 
liteal, and, passing 
between the two 
heads of the tibialis 
posticus muscle and 
then between the 
tibia and fibula in 
the interspace above 
the upper margin of 
the interosseus 
membrane, it 
reaches the anterior 
surface of the leg, 
and lies upon the 
interosseous mem- 
brane (Fig. 112). 
In the upper part of 

1. Patella. 

2. External malleolus. 

3. Deep fascia. 

4. Tibialis anticus muscle, 
o. Extensor lougus digi- 

torum muscle. 

6. Peroneus lougus and 
brevis muscles cut 
across. 

7. Border of fibula. 

5. Extensor proprius pol- 
licis muscle. 

9. Flexor longus pollicis. 

10. Anterior tibial artery. 

11. 11. Venae comites. 

12. Anterior tibial nerve. 

13. Dorsalis pedis artery. 

14. The peroneal artery. 



Fin. 112. 




14' 



The Anterior Tibial Artery. 



l62 LIGATIONS. 

its course it is connected to the interosseous membrane by 
delicate bands of fibrous tissue, which pass over it ; and 
below, it lies upon the anterior surface of the tibia and the 
anterior ligament of the ankle-joint, passing beneath the 
anterior annular ligament. As it descends it changes its 
relations to the muscles, by reason of the direction the 
tibialis anticus and the extensor proprius pollicis take t*o 
their points of insertions, lying above, between the tibialis 
anticus and extensor longus digitorum, in the middle por- 
tion of the leg between the tibialis anticus and extensor 
proprius pollicis, and in the lower part between the tendon 
of the extensor proprius pollicis and the inner tendon of 
the extensor longus digitorum. Its course may be indi- 
cated by a line drawn from the inner side of the head of 
the fibula to a point midway between the two malleoli. 

The anterior tibial nerve lies to the outer side of the 
vessel in its entire extent. In the middle it is in very close 
relation, getting somewhat upon its anterior surface. 
Venae comites are placed upon either side of the artery, 
and should be separated before passing the ligature. 

Course — From the lower border of the popliteus mus- 
cle, forward through the interspace between the tibia and 
fibula above the upper border of the interosseous mem- 
brane, and downward on the anterior surface of the mem- 
brane to a point midway between the malleoli. 

Swface markings — Crest of the tibia and tibialis anticus 
muscle. 

General relations : In front — Skin, superficial and deep 
fasciae, tibialis anticus, extensor longus digitorum, and 
extensor proprius pollicis muscles, anterior tibial nerve, 
and anterior annular ligament. 

Behind — Interosseous membrane, tibia, and anterior 
ligament of the ankle-joint. 



THE ANTERIOR TIBIAL ARTERY. 1 63 

Inside — Tibialis anticus and extensor proprius pollicis 
muscles. 

Outside — Anterior tibial nerve, extensor longus digi- 
torum and extensor proprius pollicis muscles. 

Guides — Tibialis anticus, tendons of the extensor longus 
digitorum and extensor proprius pollicis. 

Structures to be avoided — Anterior tibial nerve and venae 
comites. 

Operation : In the upper third. — Turning the limb in- 
ward and extending it, an incision four inches in length 
is made over the course of the artery through the skin, 
midway between the crest of the tibia and the outer border 
of the fibula. The superficial and deep fasciae are divided 
next on the director, and the septum between the tibia- 
lis anticus and extensor longus digitorum is sought for. 
This may be recognized as the first intermuscular space 
from within outward, and by a white line at the lower part 
of the wound. The different muscles should also be 
brought into action by moving the foot, which will assist 
in distinguishing the line of separation. Flexing the foot, 
so as to relax the muscles, they are separated with the 
handle of the knife or finger, and the artery brought into 
view as it lies on the interosseous membrane, embraced 
between the venae comites, with the anterior tibial nerve 
to the outside. Separating the veins from the artery, the 
ligature needle is passed from without inward. 

In the middle third. — At this point the artery is reached 
by an incision, three inches in length, over the course of 
the vessel, somewhat nearer to the crest of the tibia than 
above, dividing the skin. The fasciae are divided, and 
the artery is found on the tibia, between the tibialis anti- 
cus and the extensor proprius pollicis muscles, with the 



1 64 



LIGATIONS. 



Fig. 




nerve lying over it. Separating 
the nerve from the artery, the 
ligature needle is passed from 
without inward (Fig. 113). In 
ligating the artery at this point, 
care should be taken to avoid 
making the incision too far from 
the crest of the tibia. It is to 
be remembered that the artery 
lies on the tibia. 

In the lower third. — An inci- 
sion three inches in length, 
dividing the skin, is made along 

1. Extensor proprius pollicis aud extensor 
longus digitorum muscles. 

2. Tibialis anticus muscle. 

3. Venaj comites. 

4. Artery. 



the external border of the tibialis anticus muscle to the 
upper margin of the anterior annular ligament, which 
passes obliquely across the limb from above downward, 
from the external to the internal malleolus. The super- 
ficial and deep fasciae are divided carefully on the direc- 
tor, and the artery sought for as it lies between the tendons 
of the tibialis anticus and extensor proprius pollicis, with 
the nerve to the outside. If not found in this position, it 
may be sought for beneath the tendon of the extensor 
proprius pollicis, or between this tendon and that of the 
extensor longus digitorum. The ligature needle is passed 
from without inward, the venae comites having been 
separated from the artery. At this point of its course the 
artery is superficial, and deep dissections should be avoided 
in seeking it. 



THE DORSALIS PEDIS ARTERY. 



l6 5 



Fig. 



The Dorsalis Pedis Artery. Surgical Anatomy. — 
The dorsalis pedis artery is the continuation of the ante- 
rior tibial, beginning at the point 
midway between the malleoli, and 
passing down the foot, near to the 
tibial border, to the first interosse- 
ous space. It is superficial in its 
entire extent, lying upon the bones 
of the tarsus, with the internal 
branch of the anterior tibial nerve 
to the outside. At its lower part 
the inner tendon of the extensor 
brevis digitorum crosses it (Fig. 
ii4)- 



1. Anterior annular ligament of the tarsus. 

2. Tendon of the extensor proprius pollicis 
muscle. 

3. Tendons of the extensor longus digitorum 
muscle. 

4. Extensor brevis digitorum muscle. 

5. Dorsalis pedis artery. 

6. Anterior tibial nerve. 



Dorsalis Pedis Artery. 




Course — From the bend of the ankle forward and down- 
ward to the first interosseous space. A line drawn from 
a point midway between the two malleoli to the space 
between the first and second metatarsal bones, indicates 
its course. 

Surface marking— Extensor proprius pollicis muscle. 

General relations : In front — Skin, superficial and deep 
fasciae, inner tendon of extensor brevis digitorum muscle. 

Behind — Astragalus, scaphoid, internal cuneiform bones 
and their ligaments. 



66 



LIGATIONS. 



Fig- II5- 



Inside — Extensor proprius pollicis muscle. 
Outside — Extensor longus digitorum muscle and ante- 
rior tibial nerve. 

Guides — Tendon of the extensor proprius pollicis mus- 
cle and inner tendon of the extensor brevis digitorum. 

Structures to be avoided — Anterior tibial nerve and 
venae comites. 

Operation. — An incision, two inches in length, not 
extending below the upper point 
of the first interosseous space, is 
made along the outer border of the 
extensor proprius pollicis muscle, 
dividing the skin. The superficial 
and deep fasciae are divided on the 
director, and the artery exposed, 
lying between the tendon of the 
extensor proprius pollicis muscle 
and the inner border of the exten- 
sor brevis muscle, with the nerve 



1. Inner tendon of the extensor brevis digitorum 
muscle. 

2. Venae comites. 

3. Tendon of tlie extensor proprius pollicis 
muscle. 

4. Dorsalis pedis artery. 




to the outside. The ligature needle is passed from with- 
out inward, avoiding the venae comites (Fig. 115). 



The Posterior Tibial Artery. Surgical Anatomy. — 
The posterior tibial artery is the larger of the terminal 
branches of the popliteal ; arising at the lower border of 
the popliteus muscle, it passes obliquely, from without in- 



THE POSTERIOR TIBIAL ARTERY. 



167 



ward, down on the 
posterior surface of 
the leg to the space 
midway between the 
internal malleolus and 
the tuberosity of the 
os calcis, where it 
terminates as the in- 
ternal and external 
plantar arteries (Fig. 
116). A line drawn 
from the middle of 
the popliteal space to 
a point behind the 
internal malleolus, will 
represent the direction 
it takes. In the upper 
part of its course it 
lies upon the tibialis 
posticus muscle, be- 



Fie. Tl6. 



3 — 




— -II 



1. Patella. 

2. Internal malleolus. 

3. Internal surface of the tibia. 

4. Deep fascia. 

5. Soleus muscle drawn aside. 

6. Tendo Achillis. 

7. Tibialis posticus. 

8. Flexor longus digitorum 
muscle. 

9. Gastrocnemius muscle. 

10. Posterior tibial artery. 

11. Venae comites. 

12. Posterior tibial nerve. 

13. 13. Internal or long 
saphenous vein. 




The Posterior Tibial Artery. 



1 68 LIGATIONS. 

neath the gastrocnemius and soleus muscles, covered by 
the intermuscular fascia, which separates it from the soleus. 

As it descends it becomes superficial, and in the lower 
third passes along the inner border of the tendo Achillis, 
a short distance from its point of origin. The posterior 
tibial nerve occupies a position to the inside, then it crosses 
the artery, and passes on the outside in the remainder of 
its course. Venae comites accompany it in its entire ex- 
tent. As it passes around the heel, it lies between the 
tendons of the flexor longus digitorum and flexor longus 
pollicis, embraced between the venae comites, with the 
nerve to the outside. 

Course — Obliquely downward and inward from the 
lower border of the popliteus muscle to a point midway 
between the internal malleolus and the point of the heel. 

Surface markings — Inner border of the tibia and the 
tendo Achillis. 

General relations : In front — Tibia, tibialis posticus and 
flexor longus digitorum muscles, ankle joint. 

Behind — Soleus and gastrocnemius muscles, deep and 
superficial fasciae, skin. 

Inside: Upper third — Origin of soleus muscle; above, 
to slight extent, posterior tibial nerve. 

Outside: Lower two-thirds — Posterior tibial nerve. 

Guides : Above — Intermuscular fascia, which separates 
the superficial and deep layers of muscles. Below — 
Tendo Achillis. 

Structures to be avoided — Internal saphenous vein, pos- 
terior tibial nerve, and venae comites. 

Operation : In the upper third. — Placing the limb on 
the outer side, with the leg flexed and the foot extended, 
so as to relax the muscles of the calf, an incision four 



THE POSTERIOR TIBIAL ARTERY. 



169 



Fig. 



inches in length is made along the inner border of the 
tibia, dividing the skin. The superficial fascia should be 
divided on the director, care 
being taken to avoid the inter- 
nal saphenous vein which passes 
up the leg in this region between 
its layers. The deep fascia being 
divided, the margin of the gas- 
trocnemius is exposed, which 
should be drawn aside, and the 
attachment of the soleus to the 
tibia divided on the director. 
Seeking the intermuscular sep- 
tum which binds the artery to the 
posterior surface of the tibialis 
posticus, it should be divided cau- 
tiously, and the artery exposed. 
Increase the flexion of the leg 
so as to relax to the fullest ex- 
tent the muscles of the calf, then 
separate the venae comites from 
the artery, and pass the ligature 
from without inward, avoiding the 
posterior tibial nerve (Fig. 117). 

The posterior tibial artery can be exposed in the upper 
portion by an incision on the posterior surface of the leg 
through the superficial muscles. This method is not 
advised, owing to the great amount of injury inflicted on 
the structures. In these operations the relations of the 
intermuscular septum to the artery should be remembered. 
This septum is a pearly white membrane which covers the 
artery, and which can be seen distinctly, and recognized 
IS 




Soleus muscle. 
Ven^e comites. 
Artery. 



, 



I70 LIGATIONS. 

by its color and the transverse direction of its fibres. It 
separates the superficial and deep muscles, and beneath it 
the artery is placed with its veins and the posterior tibial 
nerve. 

In dividing the attachment of the soleus muscle to the 
tibia, care should be taken to avoid severing at the same 
time the origin of the flexor longus digitorum. If this 
precaution is neglected, the substance of the muscle will 
be invaded and the artery missed. Its position should be 
remembered as being on the posterior surface of the 
tibialis posticus muscle, covered by the intermuscular 
septum. 

In the middle third. — The limb being in the same posi- 
tion as for the ligation in the upper third, an incision 
three inches in length midway between the inner border 
of the tibia and inner edge of the tendo Achillis should 
be made, dividing the skin. Fixing the position of the 
interna] saphenous vein, the superficial and deep fasciae 
should be divided on the director, avoiding it. Seek the 
edge of the tendo Achillis, and divide the layers of fascia 
connected with it. The artery, surrounded more or less 
by fat, will be found along the inner edge of the flexor 
longus digitorum, accompanied by its veins, with the 
nerve to the outside. The ligature should be passed from 
without inward, avoiding the nerve. 

In the lower third. — An incision two inches in length is 
made along the inner border of the tibia, and three-quar- 
ters of an inch posterior to it, dividing the skin. The 
sheath of the artery, with its venoe comites, will be found 
imbedded in fat, which is peculiar to this region. Sepa- 
rating the veins from the artery, the ligature should be 
passed from without inward, to avoid the posterior tibial 



THE PERONEAL ARTERY. 



171 



nerve, which lies to the outside. In this operation care 
should be taken to avoid opening the sheaths of the ten- 
dons which are placed on 
the posterior surface of the Fi S- Il8 « 

tibia (Fig. 118). 

At the ankle. — A semi- 
lunar incision two and 
one-half inches in length 
should be made midway 
between the internal mal- 
leolus and the heel, divid- 
ing the skin. The strong 
and dense fascia (the in- 
ternal annular ligament) 
covering the vessels and 
nerves, which is now ex- 
posed, and which is closely 
adherent to the sheaths of 
the tendons, should be 
divided cautiously on the 

director. The sheath of the vessels should be opened, 
the venge comites separated from the artery, and the liga- 
ture passed from below upward, avoiding the posterior 
tibial nerve. 




1. Skiu and fasciae. 

2. Posterior tibial nerve. 

3. Vena; comites. 

4. Posterior tibial artery. 



The Peroneal Artery. Surgical Anatomy. — The 
peroneal artery arises from the posterior tibial and passes 
down the posterior surface of the leg along the outer or 
fibular side, terminating in branches on the back and 
outer side of the ankle. A line drawn from the posterior 
part of the head of the fibula to the external border of the 
tendo Achillis at the malleolus will indicate its course. 



172 LIGATIONS. 

Course — From point of origin from the posterior tibial 
artery an inch below the lower border of the popliteus 
muscle, obliquely outward to the fibula, descending along 
its inner border to the ankle (Fig. 112, 14). 

Surface marking — The fibula. 

General relations: In front — Tibialis posticus and 
flexor longus pollicis muscles. 

Behi?id — Soleus and flexor longus pollicis muscles, 
fasciae, and skin. 

Outside — Fibula. 

Guide — Flexor longus pollicis muscle. 

Structures to be avoided — The peroneal nerve. 

Operation. — An incision three inches in length, paral- 
lel with, but behind, the external border of the fibula, 
should be made, dividing the skin. The attachment of 
the soleus muscle to the fibula must be divided, if neces- 
sary, and the muscle drawn inward. The origin of the 
flexor longus pollicis is to be detached, and the artery 
will be found to the inner side, lying beneath a strong 
aponeurosis on the anterior surface of this muscle, which 
must be divided. The ligature should be passed so as to 
avoid the peroneal nerve. 



PART IV. 

AMPUTATIONS. 



Amputations are operations which are performed for 
the purpose of removing a limb or a part of a limb from 
the body. The point of separation may be either in the 
continuity of the limb, through the bone, or at the articu- 
lation, between two or more bones. 

INSTRUMENTS USED IN AMPUTATIONS. 

The instruments required in performing these operations 
are knives, saws, bone-nippers, dissecting forceps, artery 
forceps, tenaculum, ligatures, sutures, suture-needles, scis- 
sors, retractors, and tourniquet. 

i. Knives. — These consist of amputating knives, large 
and small, the catlin, bistoury, and scalpel. 

The amputating knives may vary in length from seven 
to twelve inches; in width, from three-eighths to three- 
quarters. They should have thick backs, the principal 
cutting edge extending the whole length of the blade, and 
the edge upon the back not longer than an inch and a 
half. They should be mounted in strong and roughened 
handles (Figs. 119, 120, 121). 

The catlin or double-edged knife (Fig. 122) is used, and 
15* (i73) 



174 



AMPUTATIONS. 



forms part of the operating cases; it is employed to 
divide the inter-osseous membranes and intervening tissues 
in amputations of the forearm and leg. It can be dis- 
pensed with, the bistoury or scalpel accomplishing this 



Figs. 126, 125, 124, 123, 122, 121, 120, 119. 




INSTRUMENTS. 



175 



portion of the operation equally well. It should not be 
used to make flaps by transfixion, as the borders are liable 
to be cut in a jagged manner by the double-cutting, edge 
of the instrument. 

The bistoury should have a narrow, sharp-pointed blade 
three inches in length, with a strong back to it (Fig. 123). 

The scalpel should have a strong blade three inches in 
length, with a broad body and a sharp point (Fig. 124). 



Fig. 127. 



Fig. 128. 



Fig. 129. 





2. Saivs. — These may be of two kinds. The one for 
larger bones should be ten inches long by two and a half 
wide ; strong, with heavy back, and teeth not too widely 
set (Fig. 127). For the bones of the hand, a small saw, 



i 7 6 



AMPUTATIONS. 



called the metacarpal saw, is employed (Fig. 128). A 
small saw, with a movable back, is used for the foot (Fig. 
126). 

3. Bone-nippers or cutting pliets are used for dividing 
the bone in amputation of phalanges or cutting off rough 
edges left by the saw. The blades should be short and 
sharp, and the handles long and strong (Fig. 129). 

4. Artery Forceps are used to seize the divided vessels. 
The blades should be toothed, so as to hold firmly, and 
expanded a short distance above the point, in order that 
the ligature may slip over easily, and not include the 
point in the knot. They should fasten with a spring or 
catch (Figs. 130, 131). 

Fig. 130. 




Fig. 131. 




5. The Tenaculum — A sharp, slightly curved hook (Fig. 
132). This is used to penetrate the coats of the vessels 
and hold it while the ligature is applied, or to pick up a 
mass of tissue when it is not possible to isolate the artery. 



INSTRUMENTS. 



177 



6. Ligatures, Sutures, Suture Needles, and Scissors have 
already been described (pp. 85-90). 

Fig. 132. 




7. Retractors. — These are formed from pieces of strong 
muslin, six to eight inches wide and of proper length to 
embrace the limb, one end being torn into two or three 
tails. They are applied around the bone to retract the 
soft structures, and prevent injury to them by the saw, and 
also to protect them from the bone dust (Figs. 133, 134). 



Fig. 133. 



O 



Fig- 134- 




In securing the flaps in apposition by sutures, that first 
introduced should be in the centre, and should be carried 
in a direction so as to pass first through the most depen- 
dent flap. The remaining sutures should be applied on 



i 7 8 



AMPUTATIONS. 



either side of the first, alternately, so as to support the 
flaps equably and prevent dragging. Care should be taken 
to avoid the introduction of too many sutures — a sufficient 
number only to bring the edges in accurate apposition 
should be used. If the subcutaneous tissue protrudes 
between the edges of the flaps as they are drawn together, 
it should be turned in and the cut surfaces placed evenly 
in contact. 

Compress, adhesive strips, and roller are required in 
the living subject to complete the dressing. 

Methods of Controlling Hemorrhage. — In perform- 
ing amputations in the living subject, it is necessary to 




METHODS OF CONTROLLING HEMORRHAGE. 



179 



Fig. 136. 



adopt means for controlling hemorrhage after section of 
the bloodvessels. For this purpose the tourniquet, an 
instrument devised by Morel in 1674 and subsequently 
modified by Petit, has been employed (Fig. 135). Within 
a few years, Prof. Esmarch, of Germany, has introduced 
an apparatus for bloodless operations, which consists 
of three yards of red elastic and four feet of rubber 
tubing, with hook and chain. The elastic bandage 
measures two and a half inches in width, and is applied 
to the limb by spiral turns, beginning at the distal point 
and terminating a short distance above the point where 
section is to be made. The rub- 
ber tubing, which is three-eighths 
of an inch in width, is then ap- 
plied by two or more turns just 
above the border of the last turn 
of the bandage, and fastened 
securely by the hook and chain 
(Fig. 136). On removal of the 
bandage, the limb presents a 
blanched appearance, and on 
section the vessels and tissues are 
found free from blood. In the 
place of the red elastic an ordi- 
nary rubber band of the same 
length and width can be em- 
ployed. To avoid a possible 
injury to the nerves of the part 
by undue pressure on the part of 
the rubber tubing, the author 

suggested, some years since, the substitution of a rubber 
band, measuring one and a half inch in width. It was 




i8o 



AMPUTATIONS. 



found to answer the purpose of making pressure equally 
as well as the tubing, and to avoid injury to the nerve 
structures. 

The instruments which are required in performing am- 




putations are arranged in a convenient manner in the am- 
putating-case (Fig. 137). 



METHODS OF AMPUTATION. 



There are two principal methods of amputation: the 
circular and the flap. The oval may be regarded as a 
variety of the circular, and the rectangular of the flap 
method. 



The Circular Method. — This operation may be de- 
scribed as consisting of three stages. 



THE CIRCULAR METHOD. 



181 



The first stage includes the division of the skin and 
superficial fascia; the second, that of the muscles and 
other structures to the bone; and the third, section of the 
bone. 

In performing the operation, the operator stands so as 
to enable him to grasp the proximal part and retract the 
superficial tissues with the left hand ; then, stooping so as 
to place his face on a level with the limb, he carries the 
amputating knife, held lightly in the right hand, around 
to the opposite side of the limb until the blade is perpen- 
dicular to the floor, pressing the heel firmly into the tis- 
sues (Fig. 138). He then makes a circular cut around 

Fig. 138. 




the limb, rising as he makes it, so as to complete the 
entire incision with one motion. 

Separating the skin and fascia by careful dissection 
(Fig. 139) to the extent of two or two and a half inches, 
the cuff or fold thus formed is turned back, and the knife 
16 



182 



AMPUTATIONS. 



is carried about the limb just below its border in the same 
manner as above described, dividing the muscles and 
other structures to the bone. A circular sweep is now 
made around the bone, dividing the periosteum, which, 
with the muscular structures, is dissected up to the extent 




Fig. 140. 




of an inch or more. The retractor is now applied, the 
tails being directed upward, and crossed in such manner 
that they, with the body of the retractor, completely 
cover the cut surfaces. The tissues being firmly pressed 
back, the saw, held vertically, is applied to the highest 
point exposed (Fig. 140), and drawn from heel to point, 
steadied carefully by the thumb-nail of the left hand, 
and the bone divided by short, light, and even strokes. 
If two bones are to be sawn, the saw should be used so 
that the smaller and most movable shall be divided first. 



THE CIRCULAR METHOD. 



183 



The vessels are now to be ligated, spiculae of bone (if 
any exist) removed by the bone nippers, the projecting 
ends of nerves and tendons retrenched, and the edges of 
the fold of skin brought into apposition transversely, and 
fastened together by means of sutures. 




In ligating arteries after amputation, the divided end is 
to be seized with the artery forceps (Fig. 141) or trans- 
fixed by the tenaculum, and drawn out (Fig. 142) from 







184 



AMPUTATIONS. 



the tissues so as to isolate it — any structures which adhere 
to the artery can be pushed back by the handle of the 
knife, or carefully removed by dissection. Great care 
should be taken to avoid the inclusion of the nerve in the 
ligature, else the most serious consequences may ensue. It 
is important that the end should be cut across straight, 
and not obliquely, and that the ligature should be applied 
a sufficient distance from the divided end to insure com- 
plete occlusion of the vessel. One end of the ligature 
should be cut off close, and the other brought out between 
the flaps at the nearest point to the surface. The most 
important vessel may be indicated by a knot tied in the 
ligature, or the two ends may be allowed to remain, and 
be then knotted. 

It is important that the ligature should be applied 
securely to the artery, and to accomplish this the reef- 
knot should always be used. To tie this knot successfully 

Fig. 143- 




the following method is given by Mr. Heath : The liga- 
ture is to be held in the palm of the right hand between 
the thumb and index finger, the end is then to be thrown 



THE CIRCULAR METHOD. 185 

round the forceps closely and caught with the left hand ; 
the right hand is now brought under the end in the left, 
when that end is to be crossed over the right thumb and 
inserted between the third and fourth fingers of the right 
hand (Fig. 143), the left hand at the same moment siezes 
the outer end, and thus an interchange is effected, and 
the ends of the threads are drawn out (Fig. 144). The 




index fingers or thumbs can be used to draw this knot 
tight (Fig. 145). The knot is completed by another tie, 
the same manoeuvre being effected, taking care to begin 
with the opposite hand to that which began before. 

As the ligatures are liable to become adherent to the 
dressings, it is a good plan to fasten them to the surface 
by short pieces of adhesive plaster, so as to prevent them 
from being pulled upon when the dressings are removed. 

The projecting ends of the nerves should be removed, 
in order to prevent them from being held between the 

16* 



1 86 AMPUTATIONS. 

flaps, and thus, after union has occurred, liable to be sub- 
mitted to pressure. The tendons should be cut off close, 
as their presence interferes with the healing process. 

Several points are to be noted by the student in the cir- 
cular operation. When the circular cut around the limb is 
made, care should be taken that the point of the knife 

Fig. 145- 




does not strike the face as it turns. It happens sometimes 
that the incisions are not made successfully because the 
knife is drawn around the part, the heel alone bei7ig kept in 
contact with the surface. The knife should be drawn 
gradually from heel to point as it passes around the limb, 
finishing the cut with the point. The amount of pressure 
to be employed varies somewhat with the condition of the 
part and of the knife, whether sharp or dull. Practice 
alone will enable the student to acquire proper knowledge 
upon this point. 

Before making the second incision, it is directed that 
the cuff of skin and fascia, which has been formed, should 
be turned up. In some cases, owing to the conical shape 



THE MODIFIED CIRCULAR METHOD. 187 

of the limb, this may be difficult to accomplish. When 
it is found difficult to turn this back, it should be slit open 
at one side. 

In making the second incision, the assistant should hold 
back the cuff, so as to avoid its section as the knife is car- 
ried around the limb. 

The periosteum is directed to be dissected up to some 
distance; this is desirable, in order to secure good repair 
in the divided end of the bone and prevent exfoliation. 

In sawing the bone the saw should be held vertically, 
so as to divide it from side to side, and thus avoid a liabil- 
ity to fracture or splintering. Proper care should always 
be taken in supporting the portion to be removed during 
this part of the operation. 

The manner in which the limb is held and supported is 
of great importance, as splintering and fracture occur fre- 
quently from want of proper knowledge upon this point. 
The limb should be covered with a towel or bandage, so 
that a firm grasp can be taken ; and, while it is firmly sup- 
ported, without being raised up or down, it should be 
drawn away with moderate force from the body in the 
line of its long axis. This action will cause a separation 
of the ends, and prevent binding of the saw, while steady 
support combined with it, will remove the weight of the 
limb. 

The circular method of amputation can be employed 
at any part of the limb ; it is preferably used where there 
are two bones or an absence of muscular structures, as in 
the lower portions of the forearm and leg. 

The Modified Circular Method. — This name is given 
to an operation which consists in forming two short flaps 



1 88 AMPUTATIONS. 

of skin and superficial fascia by cutting from without in- 
ward, and dividing the muscles by a circular incision (Fig. 
146). It may be employed in cases where there is a 
redundancy of muscular tissues. 

Fig. 146. 




The Flap Method. — Amputation by the flap method 
consists in the division of the tissues so as to form one or 
more flaps, with which the end of the bone is covered. 
These flaps may be made by cutting from without inward 
to the bone, or from within outward, the knife transfixing 
the tissues, and cutting from the bone to the surface. In 
some instances, one flap is made in the first way, and the 



THE FLAP METHOD. 189 

other in the second. The flaps may vary in number from 
one to two or more, according to the circumstances of 
each case. The length also varies according to the size 
of the limb. A safe rule to adopt is to make them equal 
in length to three-quarters the diameter of the limb at the 
point of section of the bone. They may be made antero- 
posterior^, laterally, or obliquely, and may include all 
of the structures to the bone, or may be made of skin and 
fascia alone, the muscles and other structures being divided 
circularly. They may be cut of equal length, or one may 
be longer than the other, according to the amount of 
muscular tissue in the part involved. They are, as a rule, 
convex in shape, terminating in a point more or less ob- 
lique. Care should be taken to avoid making them too 
oblique; and it should be remembered that it is always 
better to have an abundance of tissue rather than too 
small an amount. In the one case the redundant tissue 
can be retrenched; in the other it may be found difficult 
to supply the deficiency. If, in any case, the flaps are 
found to be too short, and there is danger of protrusion 
of the bone, the bone should then be sawn through at a 
higher point. 

In performing the operation by transfixion the operator 
stands so as to grasp the proximal part of the limb firmly 
with the left hand. Raising the tissues so as to see that 
the flaps to be made will be, as nearly as possible, of equal 
size, the point of the amputating knife is entered on the 
side, midway between the upper and lower borders of the 
limb, and pushed inward until it strikes the middle of the 
bone. The handle of the knife is then depressed until 
the point is carried over the bone, and then elevated, re- 
turning the blade to the horizontal position, in order to 



190 



AMPUTATIONS. 



bring the point out exactly opposite to the point of en- 
trance. The knife, still in the horizontal position, and in 
close contact with the bone, is carried downward with a 
sawing motion to a sufficient distance, and then, turning 
its edge to about an angle of 45 °, it is carried upward 
and outward until the tissues are divided. In cutting out- 
ward, the handle of the knife should be gradually turned 
in the hand, so that when the edge leaves the tissues it 
will look directly upward. In this way, a pointed flap 
will be avoided. Turning back the flap, the knife is re- 
entered at the same point as before, carried under the 

bone by movements 
Fig- 147- similar to those used 

in making the first flap, 
the point brought out 
as before (Fig. 147), 
and the flap cut in the 
same way as the first. 
The flaps are now held 
back by the retractor, 
and the remaining 
tissues and periosteum 
divided by a circular 
cut of the knife. The 
periosteum is dissected 
back to a sufficient 
extent, and the bone 
sawn. The arteries are 
ligated, nerves and tendons retrenched, and sutures intro- 
duced, as described in the circular method. 

In transfixing the tissues in this operation in the arm 
and thigh, it is important that the principal artery should 




THE FLAP METHOD. 191 

not be pierced by the point of the knife in making the 
first flap, as a punctured wound or a longitudinal slit will 
be made in the vessel which may cause serious trouble, 
the operator being compelled to dissect back to a sound 
portion of the artery in order to apply the ligature. If 
the position of the main artery is well ascertained before 
the incisions are commenced, the point of the knife can 
be passed so as to avoid it. An effort should always be 
made to leave it in the flap which is made last, thus defer- 
ring its division to the later stages of the operation. 

In the arm and thigh, where the superficial fascia is 
usually abundant and the skin is very elastic and moves 
readily over the subjacent muscular tissues, care must be 
taken, in cutting from within outward, to retract the skin 
firmly, so that when the section is completed the muscles 
and skin will be divided on the same line. If this import- 
ant injunction is unheeded, the operator will find a pro- 
jecting mass of muscular tissues without sufficient skin to 
cover them. This mass should be retrenched, otherwise, 
if an attempt is made to pull the skin forcibly over it and 
then apply sutures, these will cut through, owing to the 
undue tension. It may be advisable, in some instances, 
when cutting from within outward, to turn the knife so as 
to divide the muscles at a higher point than the skin, thus 
reducing the muscular mass in the flap and giving a longer 
skin flap. 

In forming antero-posterior flaps by transfixion, the 
anterior flap should be made first. In the lateral flap 
operation, the outer flap should be cut first. As a rule, 
the principal artery should be contained in the flap formed 
last. 

An effort should be made, in cutting the flaps in the 



192 AMPUTATIONS. 

living subject, to form them with regard to shape and size, 
so as to obtain a stump to which an artificial appliance can 
be adapted with comfort to the individual, the line of the 
cicatrix being so placed as to be free from pressure. 

In the flap method, the flaps may also be made by cut- 
ting from without inward. When this plan of forming 
them is adopted, the amputating knife or, if preferred, a 
large scalpel should be entered on one side, at the point 
fixed upon for section of the bone, and carried over the 
front of the limb, making a curvilinear incision downward 
to the extent necessary to give proper length to the flap, 
bringing it out at a point just opposite to that of entrance. 
With this incision, the skin and superficial fascia, or the 
entire structures to the bone, are divided. The posterior 
flap may be formed in the same way, or by transfixion. 

The Oval Method (Scoutetten's method). — This 
method, as stated above, may be regarded as a modifica- 
tion of the circular. It may be employed when amputa- 
tion is performed in the continuity of a limb, but it is 
more frequently adopted in disarticulations or amputations 
through the joints. The incision is made by introducing 
the knife a few lines above the point of section of the bone 
or above the joint, carrying it downward in a vertical line 
for a short distance, and then sweeping it about the limb 
in an oblique direction, dividing all the structures to the 
bone, and returning to the point of entrance. It may also 
be made by two. incisions in the shape of the letter V re- 
versed, these being made first and then united by a trans- 
verse cut. 

The Rectangular Flap Method (Teale's method). — 
This is a modification of the double flap, and consists in 



THE RECTANGULAR FLAP METHOD. 



193 



forming two rectangular flaps, a long and a short one. 
The length and breadth of the long flap should be equal 
to one-half (preferably one-third) the circumference of the 
limb at the point of section of the bone, and the short 
flap, which should contain the vessels, should measure one- 
eighth the circumference, or one-fou?'th the length of the 
long flap. The lines of incision should be traced out upon 
the part (Fig. 148), and in cutting the flaps the knife 



Fig. 148. 



Fig. 149. 



Fig. 150. 




should be carried to the bone, including all of the struc- 
tures. The flaps should be dissected up, ahH the bone 
divided as in the other methods, care being taken to remove 
all rough points and spiculae (Fig. 149). The long flap is 
17 



194 AMPUTATIONS. 

then drawn over the end of the bone, and attached by sutures 
to the short one at the end and sides. The apposed edges of 
the long flap should also be secured by sutures (Fig. 150). 

The principal points to be observed in performing 
amputations may be embraced in a few general statements : 

I. The patient or subject should be placed in the re- 
cumbent position ; the operator should take a position 
which will permit him to control his movements without 
restraint. The table should be firm and high, so as to 
prevent motion and unnecessary fatigue to the operator in 
bending over it. 

II. The assistants should perform the duties assigned 
them with promptness; no delay on their part should 
attend the delivery of the instruments as they are required, 
the supply of sponges in proper condition, the supply and 
the proper application of the ligatures. Perfect quietude 
should be maintained, and no conversation should be 
indulged in except that which relates to the performance 
of the operation in hand. The office of the assistant who 
administers the anaesthetic agent is a most responsible one ; 
his entire attention should be given to the duty assigned 
him. He should carefully watch the state of anaesthesia 
in which the patient is placed, as manifested by the cir- 
culation, respiration, and other symptoms. He should 
endeavor to maintain a uniform effect upon the patient of 
the agent used; under no circumstances should he leave 
the patient or take part in any of the other duties of the 
operation. 

III. The- proximal part should be grasped firmly, and 
the integument drawn upward so that sufficient length will 
be given to this portion of the flap. Care should always 



RULES TO BE OBSERVED. 195 

be taken to cut the flaps of sufficient length. Redund?nt 
tissues should be retrenched. Flaps cut too short req» ire 
section of the bone at a higher point. 

IV. As a general rule, as little of the bone as po.-./ible 
should be sacrificed. In amputations for the removal of 
diseased structures, it is important to cut through the bone 
at a point sufficiently beyond the disease to insure healthy 
flaps. In injuries, on the contrary, all of the soft struc- 
tures remaining should be utilized in forming the flaps, 
and as much of the bone saved as possible. 

V. The periosteum should be dissected up to the extent 
of an inch or more, so as to assist in the reparative pro- 
cess which occurs about the end of the bone. 

VI. The bloodvessels requiring ligation should be com- 
pletely isolated before the ligatures are applied. Great 
care should be taken to avoid the inclusion of the nerve 
in the ligature. The projecting ends of the nerves and 
tendons should always be cut off. 

VII. In approximating the edges of the flaps, the sutures 
should be introduced to such depth as is necessary to afford 
proper support. In removing the sutures, they should be 
cut with the scissors at the side, just beyond the edge of 
the wound, and withdrawn, the borders of the wound 
being supported by the thumb and index finger of the free 
hand. If wire sutures are used, they should be divided 
in the same manner, or untwisted, the cut, or free, ends 
being bent back so as to straighten them, and the suture 
removed by gentle, even traction ; usually more force is 
required to remove the wire suture, and, therefore, care 
should be taken to support carefully the edges of the 
wound. 



196 



AMPUTATIONS. 



''g- J 5I- 



SPECIAL AMPUTATIONS. 

THE LOWER EXTREMITY. 

Amputation of the Foot. Surgical Anatomy. — The 
foot is the terminal part of the lower extremity, and con- 
sists of three portions, the tarsus, metatarsus, and phalanges 
(Fig. 151). 

Bones. — The Tarsus is composed of seven irregular 
bones, the os calcis, astragalus, cuboid on the outside, 
scaphoid on the inside, internal, mid- 
dle, and external cuneiform bones, 
placed between the cuboid and the 
inner border of the foot. 

The Metatarsus consists of five 
bones, numbered from within out- 
ward, and classified as long bones. 

The Phalanges are fourteen in num- 
ber, two for the great toe and three 
for the remaining toes, and are enu- 
merated from the metatarsus. These 
are also classified as long bones. 

Ligaments. — The bones of the 
tarsus are attached to each other by 
strong dorsal, plantar, and interosse- 
ous ligaments, with intervening syno- 
vial membranes. The articulations 
between the various bones of the tar- 
sus are of the diarthrodial form, em- 
bracing the arthrodia and the enar- 
throsis. The metatarsal bones are 
united to the last row of tarsal bones 
and to each other by dorsal, plantar, 
and interosseous ligaments. They are 




1-5. Metatarsal bones. 

6. Tibia. 

7. Fibula. 
S. Astragalus. 

9. Os calcis. 

10. Scaphoid. 

11. Cuboid. 

12. Internal cuneiform. 

13. Middle cuneiform. 

14. External cuneiform 
15-15. Phalanges. 



AMPUTATION OF THE FOOT. I97 

connected with the first phalanges by an anterior plantar 
and two lateral ligaments. 

The phalanges are bound together by plantar and lateral 
ligaments. Synovial membranes line the joints. 

Muscles. — The upper or dorsal surface of the foot is 
covered by the tendons of the extensor muscles, which 
take origin on the anterior surface of the leg, and by the 
fleshy bellies of the extensor brevis digitorum. 

The plantar surface or sole of the foot is well protected 
by the dense plantar fascia and the thick, fleshy masses 
formed by the flexor brevis digitorum and muscles of the 
great and little toes. The spaces between the metatarsal 
bones are occupied by dorsal and plantar interossei muscles. 

Articulations. — As amputation is performed at the vari- 
ous articulations of the foot, it is important to study the 
nature and position of these very carefully. The articula- 
tion of the phalanges with each other and with the meta- 
tarsus is quite regular, and does not differ materially from 
that observed in the hand. Between the metatarsus and 
the second row of bones of the tarsus, the line of articula- 
tion is irregular, owing to the projection backward of the 
head of the second metatarsal bone, and its interlocking 
with the three cuneiform bones (Fig. 151). The mortise 
formed by the three cuneiform bones has the following 
measurements : the internal wall is one-third of an inch 
deep, and has a direction obliquely backward and out- 
ward ; the external wall is one-sixth of an inch deep, and 
its direction is obliquely backward and inward ; the pos- 
terior wall measures about one-half of an inch in width, 
and is transverse. This position of the head of the second 
metatarsal bone should be particularly borne in mind in the 
attempts to effect disarticulation. The position of the 

17* 



I98 AMPUTATIONS. 

articulation on the outside is indicated by a point just be- 
hind the tuberosity of the fifth metatarsal bone. On the 
inside it lies one inch in front of the tuberosity of the 
scaphoid. 

The next line of articulation is a partial one existing 
between the heads of the three cuneiform bones and the 
base of the scaphoid, limited on the outside by the body 
of the cuboid. In disarticulation through the tarsus, this 
articulation is sometimes opened by mistake. The error 
can be detected at once by observing the three articulating 
facets on the base of the scaphoid. 

The line of articulation between the astragalus and 
scaphoid and the os calcis and cuboid is, in its nature, 
compound, being convex anteriorly between the astragalus 
and scaphoid, and concavo-convex anteriorly between the 
os calcis and cuboid. On the outside, a point midway be- 
tween the external malleolus and the tuberosity of the fifth 
metatarsal bone, indicates the position of the articulation, 
while a point just back of the tuberosity of the scaphoid 
fixes the position on the inside. 

Bloodvessels. — The arteries which supply the foot are' 
the dorsalis pedis, on the dorsal surface, and the plantar 
arteries on the plantar surface, with their venae comites. 
On a level nearly with the line of articulation, between 
the tarsus and metatarsus, the arteries form arches across 
the surfaces of the foot, from which are given off branches 
which terminate in two digital branches on each surface 
of the toes. 

Nerves. — The nervous supply to the foot is derived 
from the anterior tibial and musculocutaneous on the 
dorsal surface, and the plantar nerves on the sole of the 
foot. Digital branches are given off, which follow the 
course of the arteries. 



AMPUTATION OF THE TOES. 1 99 

Amputation of the Toes. Methods. — At the phalan- 
geal articulations, or in the continuity of the phalanges, 
by the circular or flap methods. At the metatarso-phalan- 
geal articulations, by the oval method. 

Operation. Through the articulation: Single -flap 
method.— The toe being firmly grasped and flexed, a 
transverse incision is made with a small narrow-bladed 
knife, cutting directly into the joint on the dorsal surface, 
over the most distinct fold which has been taken as a guide 
to the joint. The lateral ligaments are now to be divided, 
and the blade of the knife is introduced behind the head 
of the phalanx to be removed. The toe being extended, 
the knife is carried downward and forward toward the end 
in close contact with the bone, making a flap of the requi- 
site length to cover the end of the bone. If necessary, 
the digital arteries are ligated, the nerves and tendons 
retrenched, and the flap brought up over the end of the 
bone, and held in apposition by means of sutures. 

Circular method. — Amputation may be performed by 
this method through the articulation by making an inci- 
sion three or four lines below, dividing the skin. Dissect- 
ing this up to the joint, the ligaments are divided and 
disarticulation effected. The cuff of skin is approximated 
in the transverse direction. 

Amputation in the Continuity of the Bones. — Either 
the circular or flap method may be employed in perform- 
ing this operation. The incision being made and the flaps 
formed, as above described, the bone is divided with the 
small saw or cutting pliers. The flaps are held in apposi- 
tion by sutures, applied as in the other forms. 



200 



AMPUTATIONS. 



Amputation through the Metatarso - phalangeal 
Articulation. By the Oval method. 

Operation. — The toe being flexed, the incision is made 
on the dorsal surface one-quarter of an inch above the 
joint, and carried obliquely down to the commissure, then 
across the plantar surface to the opposite side,, the toe 
being extended, and thence obliquely upward to the point 
of departure. The extensor tendon, the lateral ligaments, 
and flexor tendons are to be divided in the order named, 
effecting disarticulation. The vessels are ligated, the 
tendons and nerves retrenched, and the edges of the wound 
approximated in a linear direction. In this operation the 
head of the metatarsal bone may be removed, if deemed 
necessary. 

Amputation of the Great Toe. By the Oval method. 

Operations. — i. This operation is performed by an in- 
cision beginning on the dorsum of the foot one-quarter of 
an inch above the joint, and then carrying it obliquely 
downward and forward on the outer side of the toe to the 



Fig. 152. 



Fig. 153. 




1, 2, 3, 4. Line of incision for removing 
first metatarsal bone with great toe. 

commissure of the toes, then under the toe to the outer 
side, and terminating at the point of departure (Fig. 152). 



AMPUTATION OF THE TOES. 



20I 



The flaps are dissected up to the joint, the extensor ten- 
dons, lateral figaments, and the flexor tendons are divided, 
completing disarticulation. The arteries are ligated, the 
tendons retrenched, and the flaps approximated in a linear 
direction (Fig. 153). 

2. The great toe may also be removed by making a straight 
incision on the inner surface of the foot, beginning one- 
half of an inch above the joint, and carrying it downward 
to the middle of the first phalanx. From the termination 
of this incision, a slightly curved incision is made on the 
dorsal surface to the commissure of the toes, and then one 
is made in a similar way on the plantar surface, joining 
the one first made. These flaps are dissected up to the 
joint, disarticulation effected, and sutures applied so as to 
bring the edges together in a transverse direction. In 
performing these operations, care should always be taken 
to secure ample flaps to cover the large surface which the 
head of the first metatarsal bone presents. 

Amputation of the Little Toe. By the Oval method. 

Operation. — This toe can be removed by incisions 
made in the same manner as those employed to effect dis- 
articulation of the great toe. 



Fig. 154. 



Fig- i55. 






202 AMPUTATIONS. 

Amputation of all of the Toes. By the Flap method. 

Operation. — Fix the positions of the articulations (Fig. 

151), and make a semilunar incision a short distance in 

front of them, carrying it from one side to the other (Fig. 

154). A short flap is then dissected 

Fl g- I 5 6 « up, the joints exposed, and opened 

by dividing the extensor tendons 

and lateral ligaments. The knife is 

passed behind the phalanges (Fig. 

155), and the flap, of requisite length, 

is made from the plantar surface (Fig. 

156). The vessels are ligated, the 

tendons retrenched, and the plantar flap is drawn up over 

the ends of the metatarsal bones, and secured by suture 

to the dorsal flap. 

Amputation in the Continuity of the Metatarsal 
Bones. By the Flap method. 

Operation. — Amputation through the metatarsal bone 
is performed by making a semilunar incision on the dor- 
sum of the foot, a short distance below the point of sec- 
tion of the bones, dividing all of the tissues to the bones. 
Dissect up the integuments to a slight extent, and form a 
plantar flap by transfixion, introducing the knife, carrying 
it, in close contact with the bones, to the commissure of 
the toes. The flaps are retracted by a six-tailed retractor, 
four of the tails being passed through the four interosseous 
spaces, and the bones divided by the metacarpal saw. 
The vessels are ligated, the tendons on the dorsal and 
plantar surfaces retrenched, and the plantar flap placed over 
the divided ends of the bones and secured to the dorsal 
flap by sutures. 



AT THE TARSOMETATARSAL ARTICULATION. 



203 



Amputation at the Tarso-metatarsal Articulation. 

By the Flap method (Lisfranc's operation). 

Bones. — The bones entering into the formation of the 
articulation are: internal, middle, and external cuneiform, 
articulating in order with the first, second, and third meta- 
tarsal bones, cuboid articulating with fourth and fifth 
metatarsal bones. 

Ligaments. — The ligaments are the dorsal, plantar, and 
interosseous. 

Line of the articulation. — A line drawn from a point 
behind the tuberosity of the fifth metatarsal bone across 
the dorsum of the foot, to a point one inch in front of the 
tuberosity of the scaphoid bone. 

Operation. — Grasping the foot firmly, a curvilinear 
incision, dividing the skin and fasciae, should be made, 



Fig. 157- 



Fig. 158. 





204 



AMPUTATIONS. 



with a strong scalpel, over the dorsum of the foot between 
the points above given, passing a short distance below the 
line of the articulation (Fig. 157). The skin and fasciae 
should be dissected up to a slight extent, and another 
incision, across the foot, on a level with the edge of the 
retracted skin, should be made, dividing the remaining 
structures down to the bones. The dorsal ligaments should 
now be divided from the fifth to the second metatarsal 
bone, then the dorsal ligament connecting the first meta- 
tarsal bone to the internal cuneiform, and lastly, the dor- 
sal ligament between the second metatarsal bone and the 
middle cuneiform, bearing in mind that the line of the 
articulation between the second cuneiform bone and the 
second metatarsal bone is one-third of an inch above the 
others (Fig. 158). The knife, being held at an angle of 
45 to the axis of the foot, with the edge turned upward, 

Fig. 159- 




should now be introduced between the first and second 
metatarsal bones, and carried up to a right angle, dividing 



AMPUTATIONS OF THE FOOT. 



205 



with its point by this movement the ligament which binds 
the head of the second metatarsal bone to the outer sur- 
face of the first cuneiform bone (Fig. 159.) Complete 
division being effected by giving the knife a rocking 
motion, it is withdrawn and applied in the same manner 
between the second and third metatarsal bones, and the 
head of the second metatarsal bone separated from the 
inner surface of the third cuneiform bone. Depressing 
the foot firmly, the joint is opened and the remaining 
attachments can be divided. The plantar ligaments and 
the tendons of the peronei muscles should now be divided. 
An amputating knife is then introduced beneath the heads 
of the metatarsal bones (Fig. 160), and a flap made from 



Fig. 160. 



Fie. 161. 





the sole of the foot by carrying the knife forward in close 
contact with the surfaces of the bones, care being taken to 
avoid the sesamoid bones of the great toe. The flap should 



206 AMPUTATIONS. 

be terminated at the roots of the toes by a broadly convex 
border (Fig. 161). 

The dorsalis pedis in the upper, and the two plantar 
arteries in the lower flap are divided, and may require 
ligation. The tendons being retrenched, the plantar flap 
is brought up over the exposed surfaces of the bones of the 
tarsus, and united to the upper flap by sutures. 

Amputation at the Tarso-metatarsal Articulation. 

(Hey's operation.) 

This operation is a modification of that just described, 
and differs from it in the method of forming the flaps and 
in the section of the internal cuneiform bone. 

Operation. — A transverse incision, dividing the struc- 
tures to the bone, is made across the foot, extending from 
the tuberosity of the fifth metatarsal bone to a point mid- 
way between the head of the first metatarsal bone and the 
tuberosity of the scaphoid. From the extremities of this 
incision, lateral incisions are made to the toes, and are 
connected by an incision across the sole of the foot, dis- 
articulating the toes. A flap from the sole of the foot is 
dissected back to the articulation, and disarticulation of 
the second, third, fourth, and fifth metatarsal bones effected 
by dividing the dorsal, plantar, and interosseous ligaments. 
The separation is now completed by dividing with the saw 
the projecting portion of the internal cuneiform bone. 
The remaining steps of the operation are performed in the 
same manner as described in Lisfranc's operation. 

Section of the second metatarsal, instead of the internal 
cuneiform bone, has been suggested in amputation at the 
tarso-metatarsal articulation. Also, disarticulation of the 
first metatarsal bone, and section of the remainder on a 
level with the internal cuneiform. 



AMPUTATIONS OF THE FOOT. 



207 



Amputation at the Medio-tarsal Articulation. By 

the flap method (Chopart's operation). 

Bones. — The bones entering into the formation of the 
articulation, on the inside, are the astragalus behind with 
the scaphoid in front ; outside, os calcis behind, with the 
cuboid in front (Fig. 162). 

Ligaments. —Dorsal: superior astragalo-scaphoid, supe- 
rior calcaneo-scaphoid, superior calcaneocuboid, and 
internal calcaneo-cuboid or interosseous. Plantar: infe- 
rior calcaneo-scaphoid, long and short calcaneo-cuboid. 

Fig. 162. Fig. 163. 





1. Astragalus. 

2. Os calcis. 

3. Cuboid. 

4. Scaphoid. 

Line of the articulation. — A line drawn across the dor- 
sum of the foot from a point one- half to three-quarters of 
an inch behind the head of the fifth metatarsal bone to a 
point one inch in front of the internal malleolus, or im- 
mediately behind the tubercle on the scaphoid bone. This 
line will be three-quarters of an inch in front of the ankle- 
joint. 

Operation.— Grasping the foot with the left hand so 



208 



AMPUTATIONS. 



that the thumb and index finger shall rest at the points 
given on the inner and outer side of the foot, indicating 
the position of the articulation, the knife, a strong scalpel, 
should be carried across the dorsum of the foot, making 
a short, slightly convex flap (Fig. 163). Dissecting up the 
integuments to a slight extent, a second incision should be 
made on a level with the retracted flap, dividing the re- 
maining structures down to the bones. Fixing the line of 
the articulation, the dorsal and interosseous ligaments are 
divided, exposing the joint fully. Dividing the plantar 
ligaments, an amputating knife is placed beneath the bones 
(Fig. 164), and a flap of sufficient length made from the 
sole of the foot (Fig. 165). The arteries which are di- 



Fig. 164. 



Fig. 165. 





vided in this operation are the dorsalis pedis in the dorsal 
flap, and the plantar arteries in the plantar flap. The ten- 
dons are retrenched, and the plantar is attached to the 
dorsal flap by means of sutures. 

In this operation attention is directed to the importance 



AMPUTATIONS OF THE FOOT. 2O0. 

of making the lateral incisions low down upon either side, 
so as to pass the knife readily under the bones, and of 
giving an oval shape to the border of the plantar flap. In 
seeking the line of the articulation, it is desirable to avoid 
getting too far back, and equally desirable to avoid ad- 
vancing so far forward as to get between the scaphoid and 
cuneiform bones. The convex and rounded articulating 
surface of the astragalus is to be distinguished from the 
articulating surface of the scaphoid, which shows three 
distinct impressions, which receive the articulating surfaces 
of the three cuneiform bones. 

Amputation at the Tibio-tarsal Articulation. By 

the flap method (Syme's operation). 

Bones. — The bones entering into the formation of the 
articulation are the lower extremity of the tibia on the in- 
side, terminating in the internal maleolus, and the lower 
extremity of the fibula on the outside, terminating in the 
external malleolus, embracing the broad trochlear surface 
of the astragalus, and forming a true ginglymoid joint free 
from lateral motion. 

Ligaments. — The ligaments of the articulation are the 
anterior, the internal lateral or deltoid, and the external 
lateral, consisting of three fasciculi. The transverse liga- 
ment of the tibia and fibula supply the place of a posterior 
ligament to the joint. 

Lines of incision: First. — From the centre of the outer 
malleolus, downward and across the sole of the heel, in a 
straight line; then upward to a point on the same level of 
the opposite side, a slight distance below the inner mal- 
leolus (Figs. 166, 167). 

18* 



2IO 



AMPUTATIONS. 



Second. — An incision across the instep, connecting the 
points of the first incision. 

Operation. — The leg being supported, and the foot 
placed at right angles to the leg, an incision should be 

made with the 
scalpel from one 
malleolus to the 
other, across the 
heel, dividing the 
structures to the 
bone, in the line 
indicated. The 
anterior incision 
across the instep 
should be next 
made, and the 
posterior flap dis- 
sected from the 
surface of the os 
calcis, the knife 
being kept in close 
contact with the 
bone, so as to 
avoid wounding 
the bloodvessels and transfixing the flap (Fig. 168.) This 
can be accomplished by placing the fingers of the left hand 
upon the heel, the thumb resting upon the edge of the 
integument, and keeping the knife between the thumb-nail 
and the surfaces of the bone, at the same time pressing 
back the tissues as they are detached. The tendo Achillis, 
when exposed, should be divided, and disarticulation ef- 
fected by cutting into the joint on the dorsum, and the 




AMPUTATIONS OF THE FOOT. 



211 



sides of the foot at the margin of the anterior flap. The 
tissues are dissected upward so as to expose the malleoli 
fully, the knife carried around so as to divide the peri- 
osteum, and the saw applied, removing a thin slice of the 
tibia with the two malleoli. 



Fig. 1 68. 




The arteries divided in this operation and requiring 
ligation are the dorsalis pedis on the dorsal surface, and 
the two plantar. The tendons having been retrenched, the 
posterior is to be placed in apposition with the anterior 
flap and secured by sutures, and an opening made in the 
posterior flap to secure drainage. 

In performing this operation, the student should bear 
in mind the importance of keeping the knife close to the 
bone in dissecting off the posterior flap, in order to avoid 
wounding the vessels which nourish the tissues, and also 
to avoid puncturing the flap, which, where it is in contact 
with the tendo Achillis, is very thin and closely adherent. 



212 



AMPUTATIONS. 



Amputation at the Tibio-tarsal Articulation (Piro- 
goff's operation). 

This operation is a modification of Syme's method, and 
consists in leaving the posterior portion of the os calcis in 
the heel flap, and placing it in apposition with the surfaces 
of the tibia and fibula, the articulating surfaces of which 
have been removed. 

Operation. — The incisions, in this operation, are made 
in the same manner as in Syme's operation. The articu- 
lation is opened from the front, and the lateral ligaments 
divided, thus disarticulating the head of the astragalus. A 
small narrow-bladed saw, or a saw such as is used in exci- 
sions, is placed obliquely upon the os calcis behind the 
astragalus, exactly upon the lesser process of the bone, or 

Fig. 169. 




sustentaculum tali, and section of the bone is made fol- 
lowing the line of incision in the soft structures (Fig. 169). 



AMPUTATIONS OF THE LEG. 2\T ) 

The malleoli are next exposed and removed by the saw, 
the tendons are retrenched, and the posterior flap containing 
the segment of the os calcis is now brought up and attached 
to the anterior flap, placing the bony surfaces in apposition. 
The direction given to the line of section of the os calcis 
in this operation is a matter of importance, in order that the 
bones may be brought accurately into apposition. Care 
should be taken to avoid making the section too oblique, 
and also in beginning the section too near the astragalus. 

Amputations of the Leg. Surgical Anatomy. — The 
leg is that portion of the lower extremity which extends 
from the thigh to the foot, and may be divided into the 
upper, middle, and lower third. 

Bo?us. — The bones which enter into its formation are 
the Patella, the Tibia, and the Fibula. 

The Patella is a large sesamoid bone placed in front of 
the knee-joint. Its purpose is to protect the front of the 
joint and to increase the leverage of the extensor quadri- 
ceps femoris muscle. 

The Tibia is a large prismoidal-shaped bone placed on 
the inside of the leg, entering by an expanded upper ex- 
tremity into the formation of the knee-joint, and below 
into the ankle-joint by its lower extremity, the internal 
malleolus. It presents on its anterior surface a sharp crest 
which lies subcutaneous its entire extent. 

The Fibula is a long slender bone occupying a position 
on the outside of the leg, articulating by its upper extremity 
with the tibia, and below terminating in the outer malle- 
olus, which forms part of the ankle-joint. 

Ligaments. — The tibia and fibula are united by the 
interosseous ligament, and are connected to the astragalus 
below by the ligaments already described (page 209). 



214 AMPUTATIONS. 

Muscles. — On the inner side of the anterior surface the 
tibia is placed, its crest being subcutaneous. In the middle 
and on the outer or fibular side of this surface the tibialis 
anticus, extensor proprius pollicis, extensor longus digito- 
rum, and peroneus tertius muscles are situated. Two lay- 
ers of muscles occupy the posterior surface; the gastro- 
cnemius, soleus, and plantaris muscles being superficial and 
forming the "calf." The deep layer consists of the pop- 
liteus, flexor longus pollicis, flexor longus digitorum, and 
tibialis posticus. On the fibular surface the peroneus lon- 
gus and brevis are placed. 

Bloodvessels. — The anterior and posterior tibial and the 
peroneal arteries pass down on the anterior and posterior 
surface of the leg, the anterior tibial lying on the anterior 
surface of the interosseus ligament until it reaches the lower 
part of the leg, while the posterior tibial and peroneal 
arteries rest upon the posterior surface of the posterior 
tibial muscle. 

Nerves. — The anterior tibial and musculo -cutaneous 
nerves are distributed to the anterior surface of the leg, 
while the posterior tibial and peroneal supply the posterior 
and outer surface (Fig. 170). 

Amputation may be performed in either the lower, mid- 
dle, or upper third of the leg, and by the circular, oval, 
rectangular, single or double flap methods. The circular 
and rectangular methods are best adapted for the lower 
third, the modified circular or flap methods are preferable 
in the middle and upper third. Amputation of the leg 
should never be performed above the tubercle of the tibia 
or the points of insertion of the biceps, semi-tendinosus, 
and semimembranosus muscles, which are necessary in 
controlling the movements of the stump. The point of 



AMPUTATIONS OF THE LEG. 



215 



election, or the most desirable point for removal of the 
leg, is from two to two and a half inches below the tuber- 
osity of the tibia. 

Fig. 170. 



1. Tibialis posticus muscle 

2. Tibialis anticus muscle 

3. Flexor longus digito- 

rum. 

4. Extensor longus digito- 

rum. 

5. Internal saphenous vein 

6. Anterior tibial vessels 

and nerve. 

7. Teudon of the plantaris 

muscle 
S. Peroneus longus muscle 
9. Posterior tibial vessels 

and nerves. 

10. Flexor longus pollicis. 

11. External saphenous 

vein and nerve. 

12. Soleus muscle with fi- 

brous intersection. 

13. Peroneal vessels. 

14. Gastrocnemius muscle. 

15. Communicans peronei 

nerve. 




13 1 1 1 

Section of the Right Leg in the upper third, 
showing structure. 



Operation: In the lower third. — Three to three and 
one-half inches above the ankle-joint. 

By the circular method. — The limb being supported by 
an assistant, the proximal part is grasped by the left hand 
of the operator, the skin firmly retracted, and the ampu- 
tating knife is carried around the limb, making a circular 
incision (Fig. 171, a), dividing the skin and superficial fascia 
in the manner already described (page 181). The cuff of 



2l6 



AMPUTATIONS. 



skin and fascia is dissected up to the extent of one and 
one-half to two inches and turned back. Guarding care- 
fully the margin of the retracted cuff, a circular incision 
is made around the limb at this point, dividing the mus- 
cles and other struc- 
Fl £- I 7 I - tures to the bones. 

These, with the pe- 
riosteum, are dis- 
sected back to the 
extent of an inch or 
more, and the inter- 
osseous membrane 
divided with the 
catlin or a large 
scalpel. A three- 
tailed retractor is 
now applied, the 
middle tail being 
passed through the 
interosseous space 
from below upward 
and the tissues firm- 
ly retracted. The 
saw, held in a vertical position, should be applied to both 
bones, drawing it from heel ,to point and dividing them 
by short, even strokes, care being taken that the fibula, 
which is the smaller and most movable bone, should be 
divided first. 

The anterior and posterior tibial and peroneal arteries 
are divided and require ligation. The anterior tibial 
artery at this point lies in front of the tibia. The posterior 
tibial and peroneal arteries should be sought for in the 




AMPUTATIONS OF THE LEG. 21 7 

interspace between the soleus muscle behind, and the 
tibialis posticus muscle in front, the former lying somewhat 
behind the tibia, and the latter along the inner border of 
the fibula. The vessels having been ligated, the tendons 
and nerves retrenched, the cuff is drawn down and the 
edges approximated by sutures in the transverse or vertical 
direction. 

In amputations of the leg it is desirable to remove the 
sharp point formed by the crest of the tibia after section. 
This should be done with the saw or bone pliers, cutting 
obliquely from above downward. 

In the lower third. By the rectangular method (Teale's 
operation). 

Operation. — The lines of incision having been traced 
out on the limb, the knife is introduced on one side at the 
point of intended section of the bones and carried down- 
ward to a distance equal in length to one-half or one-third 
the circumference of the limb, dividing all of the struc- 
tures to the bone (Fig, 148) A similar incision is made 
on the opposite side, and the two are united by one made 
transversely across the anterior surface of the leg. The 
flap, containing the skin and muscular structures, is now 
dissected up, care being taken to avoid wounding the an- 
terior tibial artery at the base of the flap. The posterior 
flap, equal in length to one-eighth the circumference of 
the limb, or one-fourth the length of the anterior flap, is 
made by a circular incision down to the bone. This flap is 
dissected up to the requisite extent, the interosseous mem- 
brane is divided, the retractor applied, and the bones 
sawn (Fig. 149). The vessels having been ligated, the 
tendons and nerves retrenched, the long flap is turned 
J 9 



2 I 8 AMPUTATIONS. 

over the ends of the bones and attached to the short flap 
by sutures (Fig. 150). 

In the middle and upper third. By the double- flap method. — 
Antero-posterior. 

Operation. — The limb being supported, the operator 
grasps the proximal part (placing the thumb and index 
finger at the points on the outer and inner surfaces of the 
leg, so as to indicate the breadth of the flap, as well as 
the point of section of the bone), retracts the skin, and 
makes a semilunar incision, either with the scalpel or 
small amputating knife, across the front of the leg from 
the inner edge of the tibia to the outer edge of the fibula, 
dividing skin and superficial fascia. This flap, which 
should be one fourth the length of the posterior and cuta- 
neous in character, is dissected up to the requisite extent, 
and, the leg being flexed slightly, the amputating knife is 
entered at the external angle of the first incision and made 
to transfix the structures on the posterior part of the leg, 
emerging at a point corresponding on the opposite side of 
the leg (Fig. 172). In passing the knife, care should be 



Fig. 172. 




taken to avoid carrying its point between the bones. This 
is likely to occur, unless the operator bears in mind that 
the edge of the fibula is on a plane posterior to that of the 
tibia, and, therefore, the handle of the knife should be 
elevated in order to depress the point as it passes behind 



AMPUTATIONS AT THE KNEE-JOINT. 2IQ 

the bone. The knife, having transfixed the tissues, is 
carried downward in close contact with the surfaces of the 
bones, forming a flap of at least four inches in length. 
The flaps are now drawn back, the remaining structures 
and interosseous membrane divided, the retractor applied, 
and the bones sawn. 

The anterior and posterior tibial and peroneal arteries 
will require ligation — possibly some of the larger muscular 
branches. Sometimes difficulty is experienced in sur- 
rounding the anterior tibial artery with a ligature, owing 
to its retraction above the section of the interosseous mem- 
brane upon which it lies. Extension of the limb will 
frequently cause it to project, so that it can be seized and 
ligated. 

The vessels having been ligated, and the tendons and 
nerves retrenched, the flaps are approximated by sutures. 

By the double-flap method. — Long external and short 
internal flap (Sedillot's operation). 

Operation. — The limb being flexed and the foot ex- 
tended, the skin is elevated over the point of intended 
section, and the amputating knife is introduced midway 
between the crest of thejibia and the fibula, and, passing 
external to the latter, is brought out in the calf of the leg 
(Fig. 171, c). Carrying it downward in close contact with 
the external surface of the bone, a long external flap is 
formed. A transverse incision, slightly convex forwards, 
divides the tissues on the inside of the leg. Dissecting up 
this flap to the requisite extent, the interosseous membrane 
is divided, the retractor applied, and the bones sawn as 
described in the other operations. 

Amputation at the Knee-joint. Surgical Anatomy. — 
The knee is a ginglymoid or hinge-joint, composed of 



2 20 AMPUTATIONS. 

three bones, the condyles of the femur above, the patella 
in front, and the upper extremity of the tibia below. The 
bones are united by fourteen ligaments, anterior, lateral, 
posterior, and internal, the more important of which are — 

The anterior or ligamentu-tn patella, a portion of the ten- 
don of the extensor quadriceps femoris, measuring three 
inches in length, and extending from the lower border of 
the patella to the point of insertion in the tuberosity of the 
tibia. 

The lateral ligaments are the internal, and the long and 
short external. 

The posterior, or the li gam en turn posiicum Winslowii, 
covers over the entire posterior portion of the joint, and 
is formed of dense fibrous tissue. 

Of the ligaments within the joint, the two crucial, ante- 
rior and posterior, and the two semilunar fibro-cartilages, 
the internal and external, are the most important in the 
surgical point of view. 

The crucial ligaments are strong interosseous bands 
attached, below, to the spine of the tibia, and, above, to 
the outer and inner condyles of the femur, crossing each 
other as they pass from below upward, the anterior being 
attached to the front of the spine of the tibia and the inner 
surface of the outer condyle, and the posterior to the back 
of the spine and the outer surface of the inner condyle. 

The semilunar fibro-cartilages are two crescentic lamellae 
attached to the borders of the head of the tibia, and serve 
to deepen the surface for articulation with the condyles of 
the femur. 

The tendons of the powerful muscles of the thigh, with 
some of the muscles of the leg, surround and protect it, 
while important bloodvessels and nerves have intimate 
relations with the joint (Fig. 173). 



AMPUTATIONS AT THE KNEE-JOINT. 



221 



Fig. 173- 




Vertical Section of the 
Knee-joint. 

1. The femur. 

2. The tibia. 

3. The patella. 

4. The crucial ligaments. 



The condyles of the femur are two large eminences, 
into which the lower extremity divides. The external 
condyle is the most prominent ante- 
riorly, and broadest, while the inter- 
nal is most prominent internally, and 
narrowest. It is to be remembered 
that they are not on the same level, 
the internal being nearly one-half 
of an inch lower than the external. 
The tuberosity on the outer surface 
of the external condyle is less promi- 
nent than that on the internal. The 
line of the articulation may be de- 
scribed as extending internally from 
a point three-quarters of an inch above 
the prominence of the tibia, across 
the lower border of the patella, and 
terminating externally three-quarters of an inch below the 
prominence of the condyle of the femur. 

Amputation through the knee-joint may be performed 
by either the flap, circular, or oval methods. Of the flap 
methods, that by the long anterior and short posterior is 
preferred. 

Amputation by the long anterior and short posterior flap 
method, retaining the Patella. 

Operation. — The knee being flexed, an incision is 
made, with the scalpel or small amputating knife, from a 
point on a line with the condyle, near to the border of the 
popliteal space, across the front of the leg, two and one- 
half inches below the tubercle of the tibia, to a point 
corresponding on the opposite side. Dissecting up this 
flap, the ligamentum patellae and the lateral ligaments are 

19* 



222 



AMPUTATIONS. 



divided, opening the joint. The crucial ligaments are 
next divided, and any remaining portions of the lateral 



Fig. 174. 




ligaments, thus completely 
exposing the joint. The 
amputating knife is now 
placed behind the head of 
the tibia, and a short poste- 
rior flap is made by cutting 
downward, keeping the knife 
in close contact with the 
bone, care being taken to 
avoid the head of the fibula. 
The popliteal artery will re- 
quire ligation, and possibly 
several of its branches (Fig. 
174). It lies in close con- 
tact with the posterior sur- 
face of the posterior ligament 
of the joint, and should be 
sought for in this position. 
The tendons and nerves are 
retrenched, and the anterior 
flap drawn down over the 
condyles of the femur, and attached to the posterior by 
sutures. 

The importance of keeping near to the margins of the 
popliteal space is to be borne in mind, in order that a 
flap of sufficient size may be secured to cover the large 
articulating surfaces of the condyles of the femur. 

By the short ci7iierior and long posterior flap. — This 
method of amputation may also be employed, in which 
case the patella is removed, and also the condyles of the 



The Popliteal Artery and its Branches 
in relation with the Knee joint. 

1. Femur. 

2, 3. Condyles of femur. 

4. Popliteal artery. 

5, 6, 7. Superior articular branches. 
8, 9. Inferior articular branches. 

10,11. Sural branches. 



AMPUTATIONS AT THE KNEE-JOINT. 



223 



femur, the long flap being taken from the muscles forming 
the calf of the leg (Figs. 175, 176). 



Fig. 175- 




Short Anterior and Long 

Posterior Flap. 
1, 2, 3. Line of incision 
for anterior flap. 



Fig. 176. 




Short Anterior and Long Posterior Flap. 
1, ?, 3. Line of incision for posterior flap. 



By the circular method. — The circular method may be 
employed in effecting disarticulation, the first incision 
being carried around the limb, through the integument, 
three or four fingers' breadths below the patella. This 
flap is dissected up to the line of the articulation, and dis- 
articulation effected by division of the ligamentum patellae, 
the lateral ligaments, the crucial and, finally, the posterior 
ligament (Fig. 177). The edges of the flaps are united 
in either the transverse or vertical direction. 

By the oval method (Bauden's method). — This opera- 
tion is described as follows: The knife is entered three 
fingers' breadths below the tuberosity of the tibia, cutting 



224 



AMPUTATIONS. 



at first transversely, then obliquely upward and around the 
limb to a point in the popliteal space two fingers' breadths 
below the line of the joint; the incision passes transversely 
across the back of the limb, and is continued obliquely 



Fig. 177. 



Fig. 178. 




Circular Method. 
1,2,3. Section of integuments. 
4, 5. Keflected integuments. 




The Oval Method. 
1, 2, 3. Oblique section of the integuments. 
4, 5. Keflected integuments. 



downward to its point of commencement. This oval flap 
is dissected up, and disarticulation effected by dividing the 
ligaments of the joint (Fig. 1 78). The vessels are ligated, 
and the edges of the flap approximated by sutures. 



Amputations of the Thigh. Surgical Anatomy. — 
The thigh is that part of the lower extremity which extends 
from the pelvis to the leg, and may be divided for the 
purposes of amputation into the upper, middle, and lower 



AMPUTATIONS OF THE THIGH. 225 

third. It is larger above than below, and has the shape 
of an inverted and truncated cone. It is composed of one 
large bone, numerous large and powerful muscles, blood- 
vessels, nerves, and lymphatics, and is covered by the 
integuments, superficial fascia, and a strong aponeurosis 
(fascia lata). 

Bone. — The bone of the thigh, the femur, is the largest, 
longest, and strongest bone in the skeleton. The superior 
extremity is divided into a globular head which enters 
into the formation of the hip-joint, a neck varying in 
length and obliquity, and two prominent processes, the tro- 
chanters — the greater on the outside and the lesser on the 
inside. The inferior extremity terminates in the condyles 
which form part of the knee-joint. 

Muscles. — Large and powerful muscles occupy the ante- 
rior, internal, and posterior surfaces of the thigh ; on the 
anterior surface the tensor vaginae femoris, sartorius and 
quadriceps extensor femoris, and subcrureus; on the inter- 
nal surface the gracilis, pectineus and adductors longus, 
brevis, and magnus; on the posterior surface the biceps, 
semitendinosus, and semimembranosus. Attached to the 
inner trochanter is the common tendon of the psoas mag- 
nus and iliacus, while to the outer trochanter and upper 
part of the shaft are the glutei, the pyriformis, the two 
obturators, the two gemelli, and quadratus femoris. 

Bloodvessels. — The femoral artery, and branches of the 
internal iliac, supply the structures of the thigh; the for- 
mer in its course down the thigh passes from the anterior 
to the inner, and then to the posterior surface; the latter 
escape from the pelvic cavity through the great sciatic 
foramen, and supply the structures in the region of the 
hip-joint. 



226 



AMPUTATIONS. 



Nerves. — The anterior crural and the great and small 
sciatic nerves with their branches, are distributed to the 
structures of the thigh, the former occupying the anterior 




Section of the Right Thigh at 
showing 
Profunda femoris vessels. 
Adductor longus muscle. 
Femoral vessels. 
Superficial obturator nerve. 
Sartorius muscle; 
Gracilis nmscle. 
External cutaneous nerve. 
Pectineus muscle. 
Eectus femoris muscle. 
Adductor brevis muscle. 
Anterior crural nerve. 
Deep obturator nerve. 



O /8 

the apex of Scarpa's Triangle, 
structure. ' 

13. External circumflex vessels. 

14. Adductor magnus muscle. 

15. Tensor vaginae femoris muscl 

16. Semimembranosus muscle. 

17. "Vastus iuternus and crureus 

muscles. 

18. Semitendinosus muscle. 

19. Vastus externus muscle. 

20. Small sciatic nerve. 

21. Biceps muscle. 

22. Great sciatic nerve. 



and inner aspect, and the latter the posterior and outer 
(Fig. 179). 

Amputation may be performed at any point of the limb, 



AMPUTATIONS OF THE THIGH. 227 

and by either the circular, oval, flap,- or rectangular me- 
thods. The flap method is that which is usually preferred, 
owing to the ease with which it is performed and the ample 
covering it gives to the end of the bone. In performing 
amputation by the flap method the tendency to powerful 
retraction on the part of the muscles of the thigh should 
be remembered, and the flaps made ample in order to 
avoid the formation of a conical stump. 

Amputation in the lower third. By the antero posterior 
flap method. 

Operation. — The tissues on the anterior surface of the 
thigh being grasped firmly, raised and retracted, the. ope- 
rator enters the amputating knife on the side of the limb 
nearest to him, carries the point directly to the centre of 
the bone, depresses the handle, passes the point over the 
bone and brings it out at a point on the opposite side cor- 
responding to the point of entrance. It is then carried 
downward in close contact with the surface of the bone 
to the distance of two to three inches as may be necessary, 
when its edge is turned and is made to cut its way out in 
an oblique direction. The knife is re-entered at the ori- 
ginal point, carried behind the bone, emerging at the same 
point as before, and the posterior flap, which should be 
somewhat longer than the anterior, is formed by cutting 
downward and then outward as in forming the first flap ; 
a circular sweep is now made around the bone, dividing 
the remaining tissues, with the periosteum ; the latter is 
dissected up to a short extent, the retractor applied, and 
the bone sawn through. The arteries divided and requiring 
ligation are the femoral and some of its muscular branches. 
The artery is found on the inside under the sartorius, with 
the vein to the outside. 



228 



AMPUTATIONS. 



The flaps are retrenched, if necessary, and united by 
sutures. 

In the lower third. By lateral flaps. 

Operation. — The tissues on the side of the limb being 
grasped so as to elevate and retract them, the knife is 
entered in the vertical direction, carried down to the bone, 
passing to one side, and emerging on the posterior surface 
of the thigh at a point exactly opposite that of entrance. 
It is then carried downward in close contact with the bone, 
and then outward, forming a flap from three to four inches 
in length as may be required. The knife is reintroduced 
at the same point, passed around the bone, and is brought 

Fig. 1 80. 




out at the same point on the posterior surface of the limb, 
and a flap formed as before (Fig. 180, b). A circular sweep 
is made, dividing the remaining structures with the perios- 
teum, the latter is dissected up to a slight extent, the re- 
tractor applied, and the bone sawn through. The vessels 
are ligated, and the flaps united as in the operation by 
antero-posterior flap. 



AMPUTATIONS OF THE THIGH. 



229 



In the lower third. By the long anterior flap. (Sedil- 
lot's operation.) 

Operation. — Amputation by this method is performed 
by making a flap from the anterior surface, equal in length 
and breadth at its free extremity to two-thirds of the cir- 
cumference of the limb at the point of section of the bone. 
This flap is made by transfixion, and should not include 
the artery. A slightly convex incision, dividing structures 
to the bone, is made on the posterior surface on a level 
with the base of the long flap. The operation is completed 
as in other methods. 

In the lower third. By the rectangular flap. 

Operation. — The lines of incision having been traced 
out on the limb (Fig. 181), two longitudinal incisions are 
made on either side, beginning at the point of intended 
section of the bone, and carried downward to such extent 



Fig. 181. 



Ficr. 182. 





23O AMPUTATIONS. 

as to form a flap measuring in length and breadth from 
one-third to one-half the circumference of the limb. These 
incisions are joined at their lower extremities by a trans- 
verse incision, and the flap, including all of the structures 
to the bone, is to be dissected up. The short or posterior 
flap, containing the vessels and equal in length to one 
fourth of the long flap, is made by a transverse incision to 
the bone. This flap is dissected up, and, the retractor 
having been applied, the bone is sawn through (Fig. 149). 
The vessels are ligated, and the sutures introduced, uniting 
the flaps (Fig. 182). 

In the lower third. By the circular method. 

Operation. — Amputation by this method is performed 
by making a circular sweep around the limb just above 
the upper margin of the patella (Fig. 180, a), dividing the 
skin and superficial fascia. Firm traction is made by an 
assistant, with both hands, in order to retract the integu- 
ments, and another circular incision is made, dividing the 
superficial muscles, the posterior being cut somewhat 
longer than the anterior. Retraction is again made, and 
the deeper muscles divided, by a circular incision, to the 
bone. The retractor is applied, the bone sawn, the vessels 
ligated, and the operation completed by approximating the 
flap with sutures. 

This method of performing the circular operation gives 
a complete covering to the end of the bone, which forms 
the apex of a hollow cone, the base being formed by the 
margins of the integuments. 

In the lower third. By the modified circular method. 

Operation. — By this method, two semilunar flaps, with 
the convexity downward, consisting of skin and superficial 
fascia (Fig. 183), are dissected up to the point of section 



AMPUTATIONS AT THE HIP-JOINT. 



23I 



of the bone, and an incision of the muscles made as in the 
circular operation just described. The semilunar flaps 
covering the muscles are united by sutures, as in the flap 
method. 

In the middle third. — Amputation at this point may be 
performed by any of the methods employed in the lower 

Fig. 183. 




third. The retraction of the muscles being here less than 
in the lower third, the flap method can be adopted with 
advantage (Fig. 180, c). 

In the tipper third, below the trochanters. — At this point 
amputation by the antero-posterior flap is deemed the most 
desirable method, and is performed in the same manner 
as in the middle or lower third. 

Amputation at the Hip-joint. Surgical Anatomy. — 
The hip-joint is an enarthrodial or ball-and-socket joint 



232 AMPUTATIONS. 

formed by the reception of the globular head of the femur 
into the cup-shaped cavity of the acetabulum, placed on 
the outside of the os innominatum. 

Bones. — The bones which enter into the formation of 
the joint are the femur and the os innominatum, consisting 
of the ilium, ischium, and pubes. 

Ligaments. — The principal ligaments of the joint are 
the capsular — ilio- femoral and teres; the cotyloid is a fibro- 
cartilaginous rim which serves to deepen the cavity of the 
acetabulum, and the transverse is placed across the ace- 
tabular notch, converting it into a foramen. The capsular 
is a strong, dense ligament which envelops the joint, being 
attached above to the margin of the acetabulum, and 
below, around the base of the neck of the femur. The 
ilio-femoral is a re-enforcing or an accessory ligament 
extending obliquely across the front of the joint. The 
teres ligament consists of a triangular band of fibres, the 
apex of which is inserted in a depression placed on the 
head of the femur a little behind and below its centre; the 
base is attached to the margins of the notch on the floor 
of the acetabulum. 

Muscles. — The joint is surrounded on all sides by large, 
strong muscles which cover and protect it. They take 
their origin in general from the different parts of the pel- 
vis adjacent to the articulation, and are attached to the 
trochanters and upper portions of the shaft of the femur. 
They have been named in connection with the muscles of 
the thigh.' 

Bloodvessels. — The bloodvessels which supply the joint 
are derived from the obturator, sciatic, internal circumflex, 
and gluteal arteries. The femoral artery passes in front 
of the articulation, separated by the capsular ligament and 



AMPUTATIONS AT THE HIP-JOINT. 



233 



the inner margin of the psoas magnus muscle, upon which 
it rests. 



Fig. 184. 




Section through the Hip joint 



Glutseus uiaximus muscle. 12 
Glutseus medius muscle. 

Glutseus minimus muscle. 13 

Pyriformis muscle. 14 

Great sciatic nerve and vessels. 11 

Tendon of obturator internus 16, 

muscle. 17 

Gemelli muscles. IS 

Biceps muscle. - 19 

Quadratus femoris muscle. 20 

Sartorius muscle. 21 

Keflected tendon of the rectus 22. 

muscle. 23 
on* 



and Gluteal region. 

, Psoas aud iliacus muscles, with 

bursa. 
, Anterior crural nerve. 
. Common femoral artery. 
. Common femoral veia. 

Profunda artery. 

Gracilis muscle. 

Semimembranosus muscle. 

Adductor brevis muscle. 

Semitendiuosus muscle. 

Obturator externus muscle. 

Adductor longns muscle. 

Adductor magnus muscle. 






J 



234 AMPUTATIONS. 

Nerves. — Branches from the sacral plexus, the great 
sciatic, obturator, and accessory obturator supply the joint 
(Fig. 184). 

The articulation being placed deeply beneath the mus- 
cular and other structures, and therefore difficult to reach 
by manipulation, it is important to establish the positions 
and relations of certain fixed points. Bernard and Huette 
give the following guides to the articulation, which should 
be borne in mind in operations upon the joint. 

1. The anterior inferior spinous process of the ilium is 
three-quarters of an inch above the superior margin of the 
acetabulum : the anterior superior spinous process is about 
an inch and three-quarters above the same point, and three- 
quarters of an inch to its outer side. 

2. The subject being erect, a line drawn from the ante- 
rior superior spinous process of the ilium to the tuberosity 
of the ischium, crosses the acetabulum at the junction of 
its posterior with its two anterior thirds. 

3. The anterior border of the acetabulum is from an 
inch to an inch and a quarter to the outer side of the spine 
of the pubes. 

4. The axis of the horizontal ramus of the pubes, ex- 
tended by an imaginary line, crosses the acetabulum at 
the junction of its superior with its middle third. 

5. The superior border of the trochanter major is on a 
level with the upper third of the cavity of the joint (Fig. 

185). 

As the capsular ligament is attached around the borders 
of the acetaculum, it is desirable, in order to divide the 
ligament readily and open the joint, to carry the knife 
around the margin of this cavity. In doing this, it should 
be remembered that the acetabulum projects further over 



AMPUTATIONS AT THE HIP-JOINT. 



235 



the head of the femur posteriorly than it does anteriorly, 
and the knife, therefore, when applied posteriorly, should 
be carried obliquely from behind forward and inward. 

Amputation at the hip joint may be performed by the 
flap method, single or double, antero-posterior or lateral, 
the oval, and the circular methods. 

By the single anterior flap. — The patient being placed 
upon the table, with the hip projecting, the limb flexed on 
the pelvis, and separated from its fellow, the operator 
takes a position on the outside of the limb, raises the soft 
structures on the anterior surface with his left hand, and 

Fig. 185. 




enters the point of a long amputating knife midway be- 
tween the anterior superior spinous process of the ilium 
and the great trochanter, and carries it to the articulation. 
Elevating the handle slightly, the point is carried over the 
articulation, transfixing the capsule as it passes, and is 
brought out at a point one inch below and in front of the 
tuberosity of the ischium, care being taken to avoid wound- 



236 



AMPUTATIONS. 



ing the scrotum, which should be held out of the way by 
an assistant (Fig. 186). The knife, kept in close contact 
with the bone, is carried downward, forming a flap six 
inches long, both sides being of equal length. The flap is 

now raised, and the artery, 
Fig. 186. which it contains, com- 

pressed by an assistant. 
With a large scalpel, the 
capsule of the joint is now 
divided on its anterior 
and inner surface, and 
the limb abducted and 
rotated outward by an 
assistant, so as to expose 
the insertion of the liga- 
mentum teres into the 
head of the femur. This 
is divided, when the head 
of the bone can be lux- 
ated and the posterior 
portion of the capsular ligament divided. The heel of the 
amputating knife is now placed behind the trochanter 
major, the point projecting as before, and the structures 
forming the posterior portion of the thigh are divided in 
a vertical direction. If desirable, this last incision can 
be made from without inward by a circular sweep of the 
knife, as in the circular method. 

The vessels which are divided, and require ligation, are 
the femoral, obturator, sciatic, external and internal cir- 
cumflex. 

The long anterior flap is drawn downward, and united 
by sutures to the posterior. 




AMPUTATIONS AT THE HIP-JOINT. 



237 



By the double- flap method : Anie?~o posterior. — In 
tation by this method, the anterior flap is formed 
same manner as in 



ampu- 
in the 



Fig. 187. 



the single anterior 
flap operation, the 
length being from 
three to four inches 
(Fig. 187). After 
the ligaments of the 
joint have been com- 
pletely severed, the 
amputating knife is 
placed behind the 
great trochanter, and 
the posterior flap, of 
the same length as 
that of the anterior, 
is made from the 
tissues on the back of the thigh (Figs. i« 




■89). The 



Ficr. 188. 



Fig. 




2 3S 



AMPUTATIONS. 



vessels are ligated, and the flaps, having been retrenched, 
if necessary, are united by sutures. 

By the double lateral flap method. — The patient being 
placed on the table, with the hip projecting beyond the 
edge, a long amputating knife is entered at a point mid- 
way between the anterior superior spinous process of the 
ilium and the great trochanter, and pushed downward 
around the head of the femur on the outer side, and made 
to emerge immediately below the tuberosity of the ischium 
(Fig. 190). The tissues over the great trochanter are 



Fig. 190. 




Fig. 191. 




drawn outward, and the knife is carried downward and 
outward around the great trochanter, in close contact with 
the bone, forming a flap four inches in length. The knife 
is reintroduced at the lower angle of the wounds its point 
carried directly upward around the neck of the femur, and 
brought out at the upper angle. The tissues on the inside 
of the thigh are now drawn inward, and the knife is carried 



AMPUTATIONS AT THE HIP-JOINT. 239 

downward around the lesser trochanter, in close contact 
with the bone, forming a flap of the same length as that 
on the outside (Fig. 191). This flap is raised, and the 
femoral artery grasped by an assistant. Disarticulation 
is effected by dividing the capsular ligament at the inner 
and upper part of the joint, next the ligamentum teres, 
the limb having been abducted and rotated outward in 
order to expose its point of insertion into the head of the 
femur, and finally completing the disarticulation by divid- 
ing the remaining portion of the capsular ligament. The 
vessels are ligated, the flaps placed in apposition, and 
united by sutures, as before described. 

By the oval method. — The position of the femoral ves- 
sels having been definitely ascertained, the patient is placed 
upon the sound side and the point of the knife entered 
above the great trochanter and an oblique incision made 
backward, outward, and downward, to a point below the 
tuberosity of the ischium. The knife is re-entered at the 
upper angle of the wound and an incision carried forward, 
inward, and downward, terminating at a point just above 
the position of the femoral vessels. The muscles on the 
outer side, which are attached to the great trochanter, are 
divided, exposing the capsule of the joint; this is divided 
externally, and the knife, being carried to the inner side, 
divides the ligamentum teres as the limb is rotated outward. 
Disarticulation is completed by cutting the remaining por- 
tion of the capsular ligament, and the knife, being placed 
behind the bone, divides the remaining structures by a 
transverse incision. The vessels are ligated and the flaps 
approximated by sutures so as to form a linear incision. 

By the circular method. — Amputation at the hip- joint 
by this method is performed by making a circular incision, 



240 AMPUTATIONS. 

dividing the skin and superficial fascia three to three and 
a half inches below the great trochanter. The skin flap 
is dissected up and a circular sweep of the knife is made, 
using great force and dividing the muscles to the joint. 
Disarticulation is effected, and the operation completed by 
ligating the vessels and approximating the flap in a direc- 
tion slightly oblique. 

By the modified circular method — Double skin flaps and 
circular division of the muscles (Skey's operation). — In 
this method of amputation the knife is entered one inch 
below the anterior superior spinous process of the ilium 
and carried down in a vertical direction for an inch and 
a half; it is then carried inward, following nearly the line 
of Poupart's ligament and about four inches below it, and 
terminates by a gentle curve, at a point about two inches 
below the tuberosity of the ischium. The second incision 
begins at the end of the vertical incision and is carried on 
the outer side of the thigh, crossing the shaft of the femur 
immediately below the trochanter major and, passing cir- 
cularly backward, terminates at the same point as the first 
incision. The flaps being dissected up to the highest extent, 
the muscles are divided by a circular sweep of the knife, 
applied with great pressure. The joint being exposed, the 
ligaments are divided and disarticulation effected. The 
operation is completed by ligating the vessels and approx- 
imating the skin flaps. 

In amputations of the lower extremity the arterial cir- 
culation may be controlled by digital compression of the 
femoral artery immediately below Poupart's ligament. It 
may also be controlled in the middle third of the thigh 
by placing a compress over the artery beneath the tourni- 
quet and applying the pressure so as to compress the vessel 



AMPUTATIONS OF THE HAND. 24I 

on the inner side of the shaft of the femur. Esmarch's 
bandage may be applied, carrying the turns to the hip- 
joint, and thus controlling the circulation in operations at 
any point of the extremity. In amputations at the hip- 
joint, pressure may be made over the artery beneath Pou- 
part's ligament, or an abdominal tourniquet may be applied 
compressing the dorta. 

UPPER EXTREMITY. 

Amputations of the Hand. Surgical Anatomy. — 
The hand is the terminal part of the upper extremity, and 
is divided into three portions — the carpus or wrist, meta- 
carpus or palm, and the phalanges or fingers. 

Bones. — The carpus consists of eight bones arranged in 
two rows; the first row contains the scaphoid, semilunar, 
cuneiform and pisiform; the second row, the trapezium, 
trapezoid, os magnum, and unciform, enumerated from 
the radial to the ulnar side. 

The metacarpus is composed of five bones and, like the 
bones of the metatarsus, are classified as long bones. 

The phala?iges are fourteen in number — two for the 
thumb and three for each finger. 

Ligaments. — The carpal bones are attached to each other 
in the rows by dorsal, palmar, and interosseous ligaments, 
and the two rows are bound together by dorsal, palmar, 
external and internal lateral ligaments. With each other 
an arthrodial joint is formed; between the two rows an 
enarthrodial articulation exists. The carpus and the four 
inner metacarpal bones are connected by dorsal, palmar, 
and interosseous ligaments, while the articulation of the 
metacarpal bone of the thumb with the trapezium is enar- 
throdial in character, the two bones being united by a 



242 AMPUTATIONS. 

capsular ligament. The metacarpal bones are connected 
together by dorsal, palmar, and interosseous ligaments, 
and with the phalanges by anterior and two lateral liga- 
ments. 

The phalanges are united by anterior and two lateral 
ligaments. The articulations between the metacarpal 
bones and the phalanges, and between the phalanges, are 
true ginglymoid joints, and are lined by synovial mem- 
branes. 

Muscles. — In addition to the tendons of the flexor mus- 
cles, which are inserted into the phalanges of the thumb 
and ringers, there are three groups of muscles placed on 
the palmar surface, and connected, respectively, with the 
thumb, little finger, and the palm. 

On the dorsal surface the extensor tendons pass to their 
insertions into the bones of the thumb and fingers, while 
the interossei fill up the spaces between the metacarpal 
bones. 

Articulations. — The articulations of the phalanges of 
the hand with each other, and with the metacarpal bones, 
present the regular lines which are observed in the pha- 
langes of the foot. Between the metacarpal and carpal 
bones, the line of articulation is quite irregular, resembling 
in character, but in less marked degree, the irregularity 
of the line of articulation between the metatarsal and tarsal 
bones of the foot. 

In the hand the second metatarsal bone is wedged in 
between the trapezium on the radial and the os magnum 
and base of the third metacarpal bone on the ulnar side, 
and the trapezoid behind. In amputation at the carpo- 
metacarpal articulation, or in excision of the second meta- 
carpal bone, this position of the head of the second meta- 
carpal bone should be borne in mind. 



AMPUTATIONS OF THE HAND. 



243 



The line of articulation between the two rows of carpal 
bones is quite irregular, owing to the projection downward 
of the scaphoid bone, placing thus the line of junction 
between the semilunar and os magnum nearly one-half of 
an inch above. From this point the line between the 
cuneiform and unciform is ob- 
lique, terminating at a point 
nearly one-quarter of an inch 
above the point of articulation 
on the opposite side (Fig. 192). 

Bloodvessels. — The structures 
of the hand are supplied by the 
radial and ulnar arteries and their 
branches, which form arches on 
the palmar and dorsal surfaces, 
and from which interosseous and 
digital branches are given off. 
The superficial palmar arch lies 
upon the anterior annular liga- 
ment, in front of the tendons of 
the flexor muscles and the median 
and ulnar nerves, while the deep arch rests upon the 
carpal extremities of the metacarpal bones. To the thumb 
and each finger four branches are distributed, placed on 
the sides, anteriorly and posteriorly. 

Nerves. — The palmar surface of the hand and fingers is 
supplied by the median and ulnar nerves and their branches, 
the digital branches accompanying the digital arteries in 
their distribution to the fingers. The radial and ulnar 
nerves, with their branches, are distributed to the poste- 
rior surface of the hand and fingers, following the course 
of the arteries. 




Metacarpal bones. 

6. Ulna. 

7. Radius. 
8-15. Cai-pal bones. 



244 



AMPUTATIONS. 



In amputations of the hand, it is of the utmost impor- 
tance that the operation should be performed in such 
manner as to save as much of the organ as possible. Every 
portion is of value to the patient, and can be made useful 
by him. Great care and discretion should therefore be 
exercised by the surgeon when called upon to perform 
amputations upon this part. A thumb and a little finger, 
or a thumb alone, or a little finger alone, if saved, will 
render better service than any artificial appliance which 
can be made. 



Amputations of the Fingers. Methods. — At the pha- 
langeal articulations or in the continuity of the bones, 
amputation may be performed by 
either the flap or circular methods. 
At the metacarpophalangeal 
articulation, the oval method is best 
adapted. 

In performing amputation through 
the articulations of the fingers, it is 
important to establish the relations 
to the joint of certain fixed and 
constant surface markings which ex- 
ist upon the palmar and dorsal sur- 
faces. Upon the palmar surface 
three distinct transverse linear de- 
pressions are observed, which, with 
the finger in extension, have the 
following relation to the corre- 
sponding articulations: that at the 
commissure of the fingers is about one inch below the 
metacarpophalangeal articulation; the middle depression 




1. Lower extremity of meta- 

carpal bone. 

2. First phalanx. 

3. Head of first phalanx. 

4. Second phalanx. 

5. Third phalanx. 



AMPUTATIONS OV THE FINGERS. 



245 



Fig. 194. 




that between the first and second phalanges is exactly 
over the joint; and the third is about a line and a half 
beyond the articulation, between 
the second and third phalanges 
(Fig. 193). When the finger is in 
a state of extreme flexion, the rela- 
tions of these depressions to the 
articulations change (Fig. 194). 

On the dorsal surface, the posi- 
tions of the articulation with the 
finger in extension are indicated by 

distinct depressions, which can be felt in making deep 
pressure over the joints. The line of the articulation is 
immediately behind the bony projections which are placed 
on the sides of the phalanges 
at their proximal extremi- Fl S- x 95- 

ties. When the finger is in . , 

extreme flexion the distal ' v } 

extremities of the meta- 
carpal bone and phalanges 
present forward and the 
line of the articulation is 
placed below the projecting 
extremity (Fig. 194). 

Operation : Through the 
articulation. By the single 
flap method. — Having ascer- 
tained the position of the 
joint, the finger is strongly 

flexed so as to prominently display the line of articulation, 
and a strong bistoury with a narrow blade is made to enter 
the joint by a transverse incision extending from one side 




21 



246 AMPUTATIONS. 

to the other (Fig. 195); the lateral ligaments are now- 
divided, completely opening the joint, and the blade of 
the bistoury is introduced behind the head of the bone 
(Fig. 196) ; keeping it in close contact with the bone, it 
is carried downward, forming a palmar flap of sufficient 
length (Fig. 197). 

Fig. 196. Fig. 197. 





The digital arteries may require ligation. Retracting 
the tendons, the palmar flap is brought upward over the 
end of the phalanx and attached by suture to the dorsal flap. 

By the double flap method. — A semilunar incision is made 
across the dorsum of the finger, the points of origin and 
termination being over the articulation at the sides. The 
flap is dissected up, disarticulation effected, and a flap of 
equal length is made from the palmar surface of the finger 
by carrying the knife downward in close contact with the 
bone. The vessels are secured, the tendons retrenched, 
and the flaps united by suture. 

By the circular method. — Amputation by this method 
may be performed by making a circular incision around 
the finger from one-quarter to one-half of an inch below 
the line of the joint. The skin is retracted and disarticu-. 



AMPUTATIONS OF THE FINGERS. 



247 



lation effected by division of the ligaments. The vessels 
are ligated, tendons retrenched, and the skin flap is drawn 
over the head of the bone and the edges approximated in 
the transverse direction. 

Amputation in the Continuity of the Phalanges. 

Operation. — Amputation in the continuity of the pha- 
langes may be performed by either the circular, flap, or 
rectangular flap methods, the incisions being made as at 
the articulations and the bone divided by the small saw or 
bone pliers. 

Amputation at the Metacarpo phalangeal Articu- 
lation. — Amputation at this articulation may be performed 
by either the oval, lateral, flap, or circular methods. 

Operation: By the oval method. — Fixing the position 
of the articulation, and flexing the finger at an angle of 
forty-five degrees, the incision is 
commenced one-quarter of an 
inch above the line of the joint 
on the dorsal surface and carried 
down to the commissure. Forci- 
bly extending the finger, the in- 
cision is continued across its base 
in the fold of the skin, and thence 
upward to the point of origin. 
Dissecting up the skin and fascia, 
disarticulation is accomplished 
by dividing the extensor tendons 
and lateral ligaments, luxating 
the head of the phalanx and dividing finally the flexor ten- 
dons (Fig. 198). The arteries should be ligated if neces- 
sary, the tendons retrenched, and the flaps united by 
sutures. 



Fig. 198. 




248 



AMPUTATIONS. 



By the lateral flap method. — In this method the lateral 
flap is formed by carrying an incision from a point over 
the articulation obliquely downward to the side of the 
finger a short distance in front of the web, thence back- 
ward to a point on the under surface of the articulation. 
An incision of a similar character is made on the other 
side of the finger, uniting with the first incision at its ter- 
mination. The flaps are dissected up and disarticulation 
effected as in the oval operation (Fig. 198). 

By the circular method. — Amputation by this method is 
performed by making a circular incision around the finger 
on a line with the fold of the skin on the palmar surface. 
Retracting the skin and fascia, a second incision is made, 
dividing the soft structures to the bone; these are drawn 
up and disarticulation is effected as in the other methods. 

Amputation of the Little Finger at the Metacarpo- 
phalangeal Articulation. By the oval method. 



Fig. 199. 



Fig. 





AT THE METACARPOPHALANGEAL ARTICULATION. 249 

Operation. — The little finger can be removed by the 
oval method, the incision being made on the side above 
the articulation in preference to the dorsal surface, as on 
the index finger, the incision extending upward so as to 
remove the metacarpal bone if required (Figs. 199, 200). 

Amputation of the Index Finger at the Metacarpo- 
phalangeal Articulation. — By the oval method. 

Operation. — Amputation of the index finger at the 
metacarpo-phalangeal articulation may be performed by 
the oval method, the incision beginning on the side in 
preference to the dorsal surface, thus forming a more 
shapely stump. 

Amputation of all of the Fingers at the Metacarpo- 
phalangeal Articulation. By the single flap method. 

Operation. — The fingers, slightly flexed, are grasped 
by the operator, the integument firmly retracted, and a 
slightly curved incision is made from one-half to three- 

• Fig. 201. 





250 AMPUTATIONS. 

quarters of an inch below the heads of the metacarpal 
bones. The extensor tendons are now exposed and divided; 
each articulation is opened and disarticulation completed 
by dividing the lateral and palmar ligaments. The knife 
is placed behind the heads of the phalanges (Fig. 201), 
and a flap is formed by carrying 
Fig. 202. - t downward and terminating the 

incision at the base of the fingers 
(Fig. 202). The digital arteries 
are to be ligated, the tendons re- 
trenched, and the palmar flap 
drawn over the ends of the bones, 
which may be removed by the 
pliers if deemed necessary, and attached by means of sutures. 
By the circular method. — The integument having been 
firmly retracted, a circular incision is carried around the 
base of the fingers, following the depressions in the skin 
at the commissures. The divided tissues are drawn back 
and disarticulation effected as in the flap method. 

Amputations of the Thumb — at the Metacarpo- 
phalangeal Articulation. 

Operation. — Amputation of the thumb at the metacarpo- 
phalangeal articulation may be performed by either the 
flap, circular, or oval methods, as in the fingers. In per- 
forming the operation care should be taken to remove the 
sesamoid bones connected with the metacarpal bone, and 
to make the flaps ample in order to cover the digital ex- 
tremity of the bone, which is broad from side to side. 

By the single flap method. 

Operation. — Amputation of the thumb at the carpo- 
metacarpal articulation by this method may be performed 



AMPUTATIONS OF THE THUMB. 



251 



by carrying an incision from before backward through the 
middle of the commissure between the thumb and index 
finger, the former being abducted, and terminating it at 
the articulation. Disarticulation is now effected and the 
external flap is formed by introducing the knife behind 
and carrying it, in close contact with the bone, to a short 
distance below the metacarpo-phalangeal articulation. The 
radial artery may be avoided if the knife, in the first inci- 
sion, is kept in close contact with the bone at the upper 
extremity. If divided, the artery with the digital branches 
should be ligated and the edges of the flaps united by 
sutures. 

By the oval method. — This operation may be performed 
by making an incision over the articulation between the 
trapezium and metacarpal bone, carrying it downward to 
the point of junction of the web with the thumb, across 



Fig. 203. 



Fig. 204. 





252 AMPUTATIONS. 

the base of the thumb, and then back to a point at the 
middle of the first incision (Fig. 203). Keeping the knife 
close to the bone, and separating the tissues carefully, the 
joint is opened on the dorsal surface, and disarticulation 
completed by dividing the remaining ligaments. The 
digital arteries are ligated, and the flap united so as to 
form a linear incision (Fig. 204). 

Amputation in the Continuity of the Metacarpal 
Bones. By the flap method. 

Operation. — In performing this operation, a curved 
incision is made across the dorsum of the hand from one 
side to the other, dividing the structures to the bone. This 
flap is dissected up, and a flap is made from the palmar 
surface in the same manner, or by transfixion. The peri- 
osteum and interosseous tissues are divided, and a five- 
tailed retractor applied. The bones are sawn through, 
vessels ligated, tendons retrenched, and the flaps united 
by sutures. 

Amputation through the Carpo-Metacarpal Articu- 
lation, leaving the Thumb. By the single flap method. 

Operation. — The hand being in a position of supination, 
a small straight knife is entered on the inner border of the 
hand, at the point of junction of the unciform with the fifth 
metacarpal bone, and carried obliquely across the palm so 
as to emerge at a point just below the thumb (Fig. 205). 
The knife is now carried downward in contact with the 
bones, and a large convex flap made from the palm. 
Placing the hand in the prone position, a semicircular 
incision is made across the dorsum, two-thirds of an inch 
below the line of the articulation, and carried inward and 



AMPUTATION AT THE WRIST-JOINT. 



253 



downward, dividing the tissues connecting the thumb and 
index finger, and joining the first incision (Fig. 206). 
The flap being retracted, disarticulation is effected by 



Fig. 205. 



Fig. 206. 




dividing the ligaments, beginning on the palmar surface. 
The radial and ulnar arteries, with, possibly, some of their 
branches, will require ligation. The tendons are re- 
trenched, and the palmar flap is drawn upward and 
attached to the dorsal by suture. 

Amputation at the Wrist-joint. Surgical Anat- 
omy. — The wrist-joint unites the forearm and carpus, and, 
with the exception of rotation, possesses all of the charac- 
teristic movements of an enarthrodial articulation. 

22 






254 AMPUTATIONS. 

Bones. — The bones which enter directly into the forma- 
tion of the articulation are the radius of the forearm, and 
the scaphoid and semilunar of the carpus (Fig. 192). The 
ulna and cuneiform bones participate indirectly, being 
separated by the intervening articular fibro-cartilage. 

Ligaments. — The ligaments of the joint are the external 
and internal lateral, and the anterior and posterior. The 
lateral ligaments are attached above to the styloid processes 
of the radius and ulna, and below to the subjacent carpal 
bones and annular ligament. The anterior ligament, a 
broad membranous band, extends from the margins of the 
lower extremities of the bones of the forearm to the three 
carpal bones below, thus uniting all of the bones which 
enter into the formation of the joint. The posterior liga- 
ment, less thick and strong, is attached above to the radius, 
and below to the scaphoid, semilunar, and cuneiform bones. 

Muscles. — The tendons of the flexor muscles pass in 
front of the joint, and the tendons of the extensor muscles 
behind. 

Bloodvessels. — The anterior and posterior carpal branch- 
es of the radial and ulnar arteries, with the anterior and 
posterior interossei and branches from the deep palmar 
arch, supply the joint. 

Nerves. — The nervous branches which are supplied to 
the joint are derived from the ulnar. 

Line of the articulation. — The line of the articulation is 
curved, owing to the convex surfaces presented by the 
union of the three carpal bones, which are received into 
the concave surfaces of the radius and ulna. The marked 
projections formed by the styloid processes of the radius 
and ulna are guides to the position of the articulation. 
It is to be remembered, however, that the styloid process 



AMPUTATION AT THE WRIST-JOINT. 



255 



Fig. 207. 



of the radius projects downward about one-sixth of an 
inch below that of the ulna. The articulation lies from a 
sixth to a fourth of an inch above a line passing through 
the extremities of the two styloid processes, the position 
of which is further indicated by the middle fold of skin 
on the palmar surface of the wrist. 

Amputation at the wrist joint may be performed by either 
the circular or the flap method. 

Operation : By the circular method. — The forearm 
being held in a position midway between supination and 
pronation, a circular incision is made around the limb 
about an inch below the sty- 
loid processes, dividing the 
skin and fascia. The cuff of 
skin and fascia being dis- 
sected up and turned back 
to a point above the line of 
the articulation, a second 
circular incision is made, di- 
viding the remaining struc- 
tures to the joint (Fig. 207). 
Disarticulation is effected by 
carrying the knife on the 
posterior part along the 
curve of the carpal bones, 
the hand being forcibly flex- 
ed. The styloid processes 

of the radius and ulna may be sawn off on a level with 
the encrusting cartilages. The radial, ulnar, and inter- 
osseous arteries will require ligation. The tendons of the 
flexor and extensor muscles should be retrenched, and the 
edges of the flap approximated in the transverse direction. 




256 



AMPUTATIONS. 



By the single flap method. — The hand being held in a 
prone position, a slightly convex incision is made from 
one styloid process to the other across the back, dividing 
the structures to the bone. The skin is retracted and the 
joint opened on the dorsal surface. Disarticulation being 
effected, the amputating knife is placed behind the bones 
of the carpus (Fig. 208), and carried downward in close 
contact with them, forming a flap of sufficient length from 
the anterior surface of the palm (Fig. 209). The styloid 



Fig. 208. 



Fig. 209. 





-ti> 



processes are sawn off, if necessary, the vessels ligated, 
tendons retrenched, and the long flap drawn upward over 
the surface of the bones, and united to the posterior flap 
by sutures. 

By the double flap method. — The hand being slightly 
flexed, a convex incision extending from one styloid pro- 
cess to the other is made, first on the dorsal, and then on 
the palmar surface of the hand, forming two flaps, each 
one inch and a half in length. These flaps are dissected 
up to the joint, disarticulation performed, and the opera- 
tion completed as in the previous methods. 



AMPUTATION OF THE FOREARM. 



257 



Amputation of the Forearm. Surgical Anatomy. — 
The forearm is that part of the upper extremity comprised 
between the arm and the hand, and is composed of two 
bones, muscles, with bloodvessels, nerves, and other 
structures. 

Bones. — The bones of the forearm are two in number, 
the radius and ulna — the former placed on the outside and 
the latter on the inside. The ulna is the largest and longest 
of the two; its upper extremity is thick and strong, firmly 
fixed in its position, and enters, by the olecranon process, 
largely into the formation of the elbow-joint. The lower 
extremity is small, movable, and, owing to the interposi- 
tion of the articular fibro-cartilage, does not participate 
directly in the formation of the wrist-joint. The radius 
is less in length and size than the ulna; its superior ex- 
tremity is small, movable, and enters but slightly into the 
formation of the elbow joint. The lower end is large and 
expanded, and forms the chief part of the wrist-joint. 

Ligaments. — The radius and ulna are united by two 
ligaments, the oblique and the interosseous membrane. 
The former extends from the base of the coronoid process 
of the ulna, to a point on the radius just below the bicipital 
tuberosity. The latter, beginning about an inch below 
the tuberosity, extends between the bones to their lower 
extremities. 

Muscles. — The muscles, which are placed on the ante- 
rior, radial, and posterior surfaces of the forearm, are 
twenty in number, and are classified as flexors, pronators, 
supinators, and extensors. In the upper and middle por- 
tions of the forearm the fleshy bellies of these muscles are 
placed, while in the lower part they terminate in tendons. 

Bloodvessels. — The structures of the forearm are supplied 
22* 



2 5 8 



AMPUTATIONS. 



by the radial, interosseous, and ulnar arteries, with their 
branches, placed on the outer, middle, and inner surfaces. 
Numerous large veins ramify in the superficial fascia on 
the anterior, lateral, and posterior surfaces. 




Section through the Middle of the Right Forearm, showing structure. 



1. Anterior interosseous vessels 

and nerves. 

2. Radial vessels and nerves. 

3. Pronator radii teres muscle. 

4. Supinator longus muscle. 

5. Flexor carpi radialis muscle. 

6. Supinator hrevis muscle. 

7. Flexor sublimis digitorum 

muscle. 

8. Extensor carpi radialis longior 

and brevior muscles. 

9. Flexor carpi ulnaris muscle. 



10. Extensor ossis metacarpi pollicis 

muscle. 

11. Ulnar vessels aud nerve. 

12. Extensor communis digitorum 

muscle. 

13. Flexor profundus digitorum 

muscle. 

14. Extensor carpi ulnaris muscle. 

15. Median nerve. 

16. Posterior interosseous vessels 

and nerve. 

17. Extensor secundi internodii 

pollicis muscle. 



AMPUTATION OF THE FOREARM. 



259 



Fig. 211. 



Nerves. — The median, ulnar, radial, and interosseous 
nerves, and their branches, are distributed to the forearm 
(Fig. 210). 

Amputation of the forearm may be performed at any 
point in the upper, middle, or lower 
third. The rule of saving as much 
of the limb as possible should be 
the guide in operations upon this 
part. 

The circular, flap, or rectangular 
flap method may be employed. In 
the lower part, the circular or 
modified circular method is best 
adapted, owing to the absence, to 
any great extent, of muscular struc- 
tures. 

In sawing the bones of the fore- 
arm, the saw should be applied so 
as to divide the smaller and most 
movable bone first. Section of the 
bones can be facilitated by pressing 
the thumb between the bones, so 
as to maintain them in position. 

In the lower third. By the circu- 
lar method. 

Operation. — The forearm being 
held in a position midway between 
pronation and supination, and the 
skin retracted, a circular incision is 
carried around the limb, dividing 
the skin and superficial fascia (Fig. 
211, 1). The cuff of skin and fascia 




260 AMPUTATIONS. 

is dissected up, forming a flap equal in length to one-fourth 
of the circumference of the limb at the point of section of 
the bones, and, if necessary, slit up, in order to turn it 
back. The cuff being held back, a second circular inci- 
sion is carried around the limb, dividing the muscular 
structures to the bone. The muscles, with the periosteum, 
are dissected up to a slight extent, and the interosseous 
membrane divided. A three-tailed retractor, the middle 
tail passing through the opening in the interosseous mem- 
brane, is applied, so as to thoroughly retract and protect 
the soft structures, and the saw applied to the bones so as 
to divide the ulna first. The radial, ulnar, and inter- 
osseous arteries will require ligation. The tendons should 
be retrenched, and the flap united in a transverse direction. 

In the lower third. By the rectangular flap method. — 
The forearm being held in a prone position, incisions di- 
viding the structures to the bone are made on either side, 
beginning at the point of section of the bones and carried 
down so as to form a flap equal in length to one-half or 
one-third the circumference of the limb. These incisions 
are joined at their points of termination by a transverse 
incision across the posterior surface of the limb, and the 
flcip is dissected up. The short flap, measuring one- fourth 
the length of the long flap, is formed by making an incision 
across the anterior surface of the limb. This flap is dis- 
sected up, the interosseous membrane divided, and the 
bones sawn through. The vessels are ligated and the long 
flap is drawn over the ends of the bones and approximated 
to the short flap by sutures. 

In the lower third. By the modified circular method. — 
This method of amputation may be employed in the lower 
third of the forearm, the skin and superficial fascia being 



AMPUTATION AT THE ELBOW- JOINT. 26 1 

divided by incisions from without inward so as to form 
antero-posterior flaps. These are dissected up and the 
remaining structures are divided by a circular sweep of 
the knife. The bones are sawn through and the operation 
completed as in the flap method. 

In the middle third. By the single flap method — In this 
operation the flap is made, by transfixion, from the struc- 
tures on the anterior surface of the forearm of sufficient 
length to cover the ends of the bones. The structures on 
the posterior surface are divided by a slightly convex 
incision. The remaining steps of the operation are per- 
formed as in the circular method, and the anterior flap 
is drawn over the ends of the bones and united to the 
posterior flap by suture. 

In the jniddle or tipper third. By the double flap method. 
— The arm being placed midway between supination and 
pronation, the point of the amputating knife is entered 
close to the inner edge of the radius and brought out 
below at the inner edge of the ulna (Fig. 211, 2). Carry- 
ing it downward in close contact with the bones to the 
extent of half an inch, it is brought obliquely outward, 
forming a semicircular flap. Re-entering it at the same 
point as before, a similar flap is made on the outside. The 
flaps being turned back, a circular .sweep is made with the 
knife around the bones, dividing the remaining structures 
with the periosteum. The periosteum is dissected up to a 
slight extent, the interosseous membrane divided, and the 
retractor applied. The bones are sawn through, the arte- 
ries ligated, and the flaps approximated by suture. 

Amputation at the Elbow-joint. Surgical Anat- 
omy. — The elbow is a true ginglymoid or hinge-joint, 
uniting the humerus with the radius and ulna. 






262 



AMPUTATIONS. 




1. Humerus. 

2. Olecranon process of ulna 

3. Head of radius. 



Bones. — The bones entering into the formation of the 
joint are the humerus above, and the radius and ulna below. 
The trochlear surface of the hu- 
merus is received in the greater 
sigmoid cavity of the ulnar, whilst 
the radial head articulates with the 
cup shaped depression on the 
head of the radius (Fig. 212). 

Ligaments. — The ligaments of 
the joints are the anterior, poste- 
rior, internal, and external. To- 
gether they form a capsular liga- 
ment which completely incloses 
the joint. 

Muscles. — .The muscles in rela- 
tion with the joints are, in front, 
the brachialis anticus; behind, the triceps and anconeus; 
internally, the common tendon of origin, of the flexor 
muscles of the forearm, and flexor carpi ulnaris; exter- 
nally, the common tendon of origin of the extensors of 
the forearm, and the supinator brevis. 

Bloodvessels. — Branches of the brachial and anastomos- 
ing branches of the brachial with the radial and ulnar 
arteries, form a network of vessels around the joint. 

Nerves. — Branches of the ulnar and musculo cutaneous 
nerves supply the joint (Fig. 213). 

Line of the articulation. — The line of articulation is 
irregular, being transverse between the radius and humerus, 
and oblique, from without inward, between the ulna and 
humerus. The condyles of the humerus are marked 
prominences, which may be taken as guides to the joint. 
The external, which is the smaller, is a quarter of an inch, 



AMPUTATION AT THE ELBOW-JOINT. 



263 



and the internal, larger and more prominent, three-quarters 
of an inch above the line of the articulation. The posi- 

Fig. 213. 



Cephalic vein 

Basalic vein and internal cuta- 
neous nerve. 

Musculo-spiral nerve. 

Median nerve. 

Brachial artery and venae 
comites. 

Anastomotica magna artery. 

Kadial recurrent artery. 

Median vein. 

Biceps muscle. 

Triceps muscle. 

Supinator longus and extensor 
carpi radialis longior muscles. 

Oi-igin of flexor and pronator 
muscles. 

Capsule of joint. 

Extensor carpi radialis longior 
muscle. 

Pronator radii teres mu cle. 

Supinator longus muscle. 

Tendon of the biceps muscle, be- 
neath which is the brachialis 
anticus muscle. 




Structures in relation -with the anterior 
aspect of the Elbow-joint. 



tions of the condyles, and their relations to the line of 
articulation, should be always borne in mind in amputa- 
tion through the joint (Fig. 214). 

Operation: By the circular method.- — The arm being 
held in the position of supination, a circular incision is 
carried around it three inches below the line of the articu- 
lation, dividing skin and superficial fascia. The cuff of 
skin and fascia is dissected up to the joint and turned back, 



264 



AMPUTATIONS. 




and a second incision is made, dividing the muscles to the 
joint (Fig'. 215). The ligaments are divided and disarticu- 
lation completed by sev- 
ering the attachment of 
the tendon of the triceps 
muscle to the olecranon 
process,, or sawing 
through the process. 
The brachial artery, 
and possibly some ar- 
ticular branches, require 
ligation. The edges of 
the flap are united in 
the transverse direction. 
By the single flap me- 
thod. — The forearm 
being in a position of 
supination and slightly 
flexed, the operator, 
standing on the inner 
side of the limb, raises 
the tissues in front of 
the joint and enters the 
amputating knife about 
an inch below the inter- 
nal condyle (Fig. 216). 
Carrying it obliquely 
across the limb in close 
contact with the bones of 
the forearm, the point is brought out a half of an inch 
below the external condyle. Cutting downward in the 
direction in which the knife is placed, a flap three inches 



1. Humerus. 

2. Radius. 

3. Ulna. 

4. External condyle, or epicondyle. 

5. Internal condyle, or epitrochlea. 

6. 7, 8. Interarticular line. 




AMPUTATION OF THE ARM. 



265 



in length is formed. The flap being retracted firmly, a 
slightly curved incision is made on the posterior aspect 
extending from the external to the internal angle of the 
first incision, opening the joint (Fig. 217). The anterior 



Fig. 216. 



Fig. 217. 




and lateral ligaments are now divided, and the insertion 
of the tendon of the triceps muscle severed or the ole- 
cranon process sawn through. The arteries are ligated 
and the anterior flap is drawn over the surface of the bone 
and secured to the posterior by sutures. 






Amputation of the Arm. Surgical Anatomy.— The 
arm is that part of the upper extremity which is embraced 
between the shoulder and elbow. It is cylindrical in form, 
flattened on the sides, and convex in front and behind. 
23 






266 



AMPUTATIONS. 



Bone. — The bone of the arm is the humerus, the longest 
and largest bone of the upper extremity. 

Muscles. — The muscles on the anterior surface of the 
arm are the coraco-brachialis, biceps and brachialis anticus. 
On the posterior surfaces, the triceps and subanconeus. 

Bloodvessels. — The brachial artery, passing down on the 
inner side, supplies with its branches the structures of the 
arm. 

Nerves. — The musculo-cutaneous, musculo-spiral, and 
internal cutaneous are the principal nerves distributed to 
the arm. The median and ulnar nerves, large trunks, pass 
down on the inner side, but give off no branches to the 
arm (Fig. 218). 

Amputation of the 
Fi S- 2lS - arm may be per- 

formed at any point 
and by either the cir- 
cular, flap, rectangu- 
lar flap, or oval 
methods. 



1. Biceps muscle. 

2. Cephalic vein. 

3. Brachial vessels. 

4. Musculo-cutaneous nerve 

5. Median nerve. 

6. Brachialis anticus mus- 

cle. 

7. Ulnar nerve. 

8. Musculo-spiral nerve. 

9. Basilic vein, with inter- 

nal cutaneous nerves. 

10. Superior profunda ves- 

sels. 

11. Inferior profunda ves- 

sels. 

12. Triceps muscle, with fi- 

brous intersection. 




Section through the Middle of the Right Uppei 
Arm, showing structure. 



AMPUTATION OF THE ARM. 



267 



Operation: In the lower or middle third. By the cir- 
cular method. — The arm being held away from the body, 
a circular incision is carried about it, dividing the skin and 
superficial fascia (Fig. 211, 3); the cuff of skin and fascia 
is dissected up to the extent of an inch or two inches ac- 
cording to the size of the limb, and turned back; a second 
incision is made at the margin of the retracted flap, divid- 
ing all of the structures to the bone (Fig. 219). The peri- 
osteum, with the muscles, is dissected up, the retractor 
applied, and the bone sawn through. The brachial artery, 
with the profunda branches, will require ligation. The 
edges of the flap are united by sutures 
in the transverse direction. 

In the lower third. By the rectangu- 
lar flap method. — In amputation by 
this method the short flap, including 





the brachial artery, is placed on the 
posterior surface of the arm. In 
making the longitudinal incisions, 
therefore, it is important to remember 
to place the one on the inner side 
above the line of the brachial artery (Fig. 220). The re- 
maining steps of the operation are the same as in the fore- 
arm (p. 260). 



268 AMPUTATIONS. 

In the upper, middle, or lower third. By the single flap 
method. — Amputation by this method may be performed 
at any point, the flap being taken from the anterior, pos- 
terior, or lateral surfaces. The flap is formed by trans- 
fixion, being made of sufficient length to cover the end of 
the bone, while the short flap is made from without inward 
by carrying the knife directly down to the bone. The 
operation is completed as in the thigh (p. 261). 

In the upper, middle, or lower third. By the double flap 
method. — In this operation the flaps are of equal length 
and may be made from the anterior and posterior, or from 
the lateral surfaces. 

Operation. — The arm being at right angles with the 
body, the tissues are grasped, elevated from the bone, and 
transfixion is made. Carrying the knife downward in close 
contact with the bone to a distance of two to two and one- 
half inches, and cutting obliquely outward, the flap is 
formed (Fig. 21 1, 5). Re-entering the knife at the same 
point, a second flap is made in a similar manner. The 
retractor is applied and a circular sweep is made with the 
knife around the bone, dividing the periosteum and the 
remaining structures. The periosteum is dissected up, the 
bone sawn through, the vessels ligated, and the flaps 
approximated by sutures. 

Amputation at the Shoulder-joint. Surgical Anat- 
omy. — The shoulder- joint is an enarthrodial or ball-and- 
socket joint, connecting the upper extremity to the shoulder. 

Bones. — The bones which form the shoulder-joint are 
the scapula and the humerus, the globular head of the 
humerus being received into the shallow glenoid cavity 
on the head of the scapula (Fig. 221). 



AMPUTATION AT THE SHOULDER-JOINT. 



269 




Ligaments. — The ligaments of the shoulder-joint are the 
capsular, coraco-humeral, and glenoid. 

The capsular is a large, loose ligament which is attached 

above to the circumference of the glenoid cavity, and 

below to the anatomical - 

_ . . Fig. 221. 

neck of the humerus, 

completely inclosing the 
joint. The coraco-hu- 
meral is an accessory 
ligament which strength- 
ens the upper and inner 
part of the capsular. The 
glenoid is a fibrous band 
covering the glenoid 
cavity, which serves to 
deepen it, and is con- 
tinuous with the long 
tendon of the biceps 
muscle. 

Muscles. — The muscles in relation with the joint are, 
above, the supra-spinatus ; below, the long head of the 
triceps: internally, the subscapulars; externally, the infra- 
spinatus and teres minor: within, the long tendon of the 
biceps. The deltoid covers the articulation on the outer 
side, in front, and behind. 

Bloodvessels. — Branches of the anterior and posterior 
circumflex and supra-scapular arteries supply the joint. 
The axillary is not in intimate relation with the articulation. 

Nerves. — Branches of the circumflex and supra-scapular 
are distributed to the joint (Fig. 222). 

Guides to the articulation. — The acromion process forms 
a prominent projection above the joint which can be easily 

23* 



1. Head of the humerus. 

2. Clavicle. 

3. Acromion process. 

4. Infra-spinous fossa. 

5. Head of humerus connected to glenoid 

cavity of scapula by capsular ligament. 



270 



AMPUTATIONS. 



recognized. It is placed nearly half of an inch above the 
glenoid cavity and projects an inch beyond it. The cora- 



Fig. 222. 




Section through Eight Shoulder-joiut, 
showing structure. 



10. 



Clavicle. 

Acromion process. 

Supraspinatus muscle. 

Trapezius muscle. 

Infra-spinatus muscle. 

Teres minor muscle. 

Teres major muscle. 

Latissimus dorsi muscle. 

Coracobrachialis and short 
head of the biceps mus- 
cle. 

Tendon of the subscapu- 
lars muscle, blended 
with the capsular liga- 
ment. 

Pectoralis major muscle. 

Deltoid muscle. 

Axillary vessels aud 



coid process is situated within and lower down, and more 
nearly in contact with the articulation. 

Amputation at the shoulder-joint may be performed by 
either the oval, single, or double flap methods. The sub- 
clavian artery should be compressed upon the first rib with 
the thumb or a padded key. 

By the oval method. (Larrey's operation.) 
Operation. — Elevating the shoulder of the patient and 
projecting it beyond the edge of the table, a vertical inci- 
sion three inches in length, beginning at the apex of the 
acromion process, is carried downward in the long axis of 
the arm, dividing the tissues to the bone. From the centre 
of this incision two oblique incisions are made, one on the 
anterior and the other on the posterior surface of the arm, 
extending respectively to the anterior and posterior borders 



AMPUTATION AT THE SHOULDER- JOINT. 



271 



of the axilla (Fig. 223). The flaps thus formed are dis- 
sected up so as to uncover the joint. The arm is now- 
rotated outward, and the insertion of the subscapular" mus- 
cle into the lesser tuberosity divided. The capsular liga- 
ment and the long tendon of the biceps muscle are next 
divided and the arm is rotated inward in order to separate 



Fig. 223. 



Fig. 224. 





1,2,3,4. Wound after Lar.ey's 
operation. 

5. Glenoid cavity and remains of 

capsular ligament. 

6, 6. Axillary vessels. 



the insertions of the supra-spinatus, infra-spinatus, and teres 
minor muscles into the greater tuberosity. Disarticulation 
is completed by dividing the remaining portions of the 
capsular ligament, and the amputating knife is placed be- 
hind the bone and the two oblique incisions are joined by 
a transverse incision, which divides the structures contain- 
ing the axillary artery (Fig. 224). The artery should be 
seized as soon as divided, and ligated. The anterior and 



272 AMPUTATIONS. 

posterior circumflex arteries, with, possibly, other articular 
branches, will require ligation. The edges of the wound 
are approximated, so as to form, when union has occurred, 
a linear cicatrix. 

By the single flap method. (Dupuytren's operation.) — 
In this operation the flap, which is formed from the deltoid 
muscle, may be made either by transfixion or by cutting 
from without inward. In the former, the knife is entered 
about an inch in front of the acromion process, carried 
directly across the joint, and brought out at the posterior 
fold of the axilla. It is then carried downward in close 
contact with the bone, and a broad flap of sufficient length 
(three to four inches) is made. This flap is raised, and 
disarticulation effected by dividing the ligamentous and 
muscular structures attached to the head of the bone by a 
semicircular incision, the head being drawn away from 
the glenoid cavity. The knife is now passed behind the 
bone and carried to the lower margins of the first incision, 
and the intervening tissues are divided on a level with the 
inferior attachments of the pectoralis major and latissimus 
dorsi muscles. In the latter, the incision is commenced 
near the anterior border of the deltoid muscle on a level 
with the articulation, descending in a curved direction to 
within two-thirds of an inch of the insertion of the muscle 
and, ascending on the posterior surface, terminates at the 
same level as the point of origin (Fig. 225). This flap is 
dissected up, disarticulation effected, and the amputating 
knife passed behind the bone, and the inferior incision 
made from within outward. The aiteries are ligated and 
the incibions united by sutures. 

By the double flap method. (Lisfranc's operation.) — In 
this method the amputating knife is entered at the outer 



AMPUTATION AT THE SHOULDER-JOINT. 



273 



side of the posterior border of the axilla, in front of the 
tendons of the latissimus dorsi and teres major muscles; 



Fisr. 226. 




passing obliquely upward in close contact with the joint, 
the handle is elevated and the point is brought out in front 
and below the clavicle in the triangular space formed by 
the acromion and coracoid processes and the clavicle (Fig. 
226). The arm being drawn from the body, and the 
deltoid muscle raised from the bone, the knife is carried 
downward in close contact with the bone, forming a pos- 
terior semicircular flap three inches in length. Disarticu- 
lation is effected, and the knife passed behind the bone, and 
the anterior flap, of the same length as the posterior, is 



274 



AMPUTATIONS. 



made by carrying it downward and forward, dividing the 
structures which contain the axillary artery (Fig. 227). 
The arteries are ligated and the flaps approximated by 
sutures. 

In amputations of the upper extremity the arterial cir- 
culation may be controlled by digital compression of the 

Fig. 227. 




brachial artery in the middle of the arm, or by the appli- 
cation of the tourniquet over a compress at the same part. 
Esmarch's bandage may be used as in the lower extremity. 
In amputation at the shoulder-joint, the subclavian ar- 
tery is to be compressed against the first rib by the handle 
of a key well padded. 



INDEX 



Acid, carbolic, solutions of, 31 
Adhesive plaster, 18 

cutting into strips, method of, 18 

heating of strips, 19 

length of strips, 18 

removal of strips, 19 

width of strips, 18 
Amputations, 173 

case of instruments for, 180 

circular method, 180 

flap method, 188 

knives used in, 174 

lower extremity, 196 

methods of controlling hemor- 
rhage in, 178 

methods of ligating arteries in, 183 

method of using the saw in, 182 

modified circular method, 187 

oval method, 192 

rectangular flap method, 192 

rules for performing 194 

Scoutetten's method, 192 

special, 196 

Teale's methol, 192 

upper extremity, 241 

arm, 26 S 

anatomy of, surgical, 265 
lower third, rectangular flap 

method, 267 
lower or middle third, circular 

method, 267 
upper, middle, or lower third, 
single flap method, 268 
double flap method, 268 

elbow-joint, 261 

anatomy of, surgical, 261 
circular method, 263 
single flap method, 264 

foot, 196 

anatomy of, surgical, 196 
Chopart's operation, 207 



I Amputations, foot — 

Hey's operation, 205 
Lisfranc's operation, 203 
great toe, oval method, 200 
little toe, oval method, 200 
medio-tarsal articulation, 207 
metatarsal bones, in continuity 

of, flap method, 202 
metatarso-phalangeal articula- 
tion, oval method, 200 
PirogofTs operation, 212 
Syme's operation, 2(i9 
tarso metatarsal articulation, 

flap method, 203 
tibio-tarsal articulation, 212 
toes, 199 

all of the toes, 202 
at articulations, 199 
in continuity of bones, 199 
forearm, 257 

anatomy of, surgical, 257 

lower third, circular met hod, 259 

modified circular method, 26 ) 

rectangular flap method, 2fi0 

middle third, single flap 

method, 261 
middle or upper third, double 
flap method, 261 
hand, 241 

anatomy of, surgical, 241 
carpo- metacarpal articulation, 
leaving the thumb, single 
flap method, 252 
fingers, 244 

all of the fingers, at the meta- 
carpophalangeal articula- 
tion, 249 
at articulations, single flap 
method, 245 
double flip method, 246 
in continuity of bone, 247 

(273; 



276 



INDEX. 



Amputations, fingers — 
index finger, 249 

at metacarpo phalangeal ar- 
ticulation, oval method, 
249 
little finger, 248 

at metacnrpo-phalangeal ar- 
ticulation, oval method, 
248 
circular method, 250 
single flap method, 249 
metacarpal bones, in continuity 

of, flap method, 252 
metacarpo- phalangeal articula- 
tion, oval method, 247 
lateral flap method, 248 
circular method, 248 
thumb, 250 

at carpo-metacarpal articula 

tion, oval methcd, 251 
single flap method, 250 
liip-joint, 231 

anatomy of, surgical, 231 
circular method, 239 
double flap method, 237 
double lateral flap method 2- 9 8 
modified circular method, 240 
oval method, 239 
single anterior flap method, 235 
knee-joint, 219 

anatomy of, surgical, 219 
Bauden's method, 223 
circular method, 223 
long anterior and short posterior 
flap, retaining the patella, 
221 
oval method, 223 
short anterior and long poste- 
rior flap, 222 
leg, 213 

anatomy of, surgical, 213 
lower third, circular method, 21 5 
rectangular flap method, 217 
Teale's method, 217 
middle and upper third, double 
flap method, antero-poste- 
rior, 218 
middle and upper third, long 
external and short internal 
flap method, 219 
shoulder-joint, 268 



A imputations at shoulder-joint — 
anatomy of, surgical, 268 
double flap method, 272 
Dupuytren's method, 272 
Larrey's method, 270 
Lisfranc's method, 272 
oval method, 270 
single flap method, 272 
thigh, 224 

anatomy of, surgical, 224 
lower third, antero-posterior 

flaps, 227 
circular method, 230 
lateral flaps, 228 
long anterior flap, 229 
modified circular method, 230 
rectangular flap method, 229 
middle third, 231 
upper third, 231 
wrist-joint, 253 

anatomy of, surgical, 253 
circular method, 255 
double flap method, 256 
single flap method, 256 
Antiseptic gauze, 31 
Antiseptic system of d-essing 

wounds, 30 
Aorta, abdominal, 141 
anatomy of, surgical, 141 
ligation of, 142 
Artery, axillary, 123 

anatomy of, surgical, 123 
ligation of, in first portion, 126 
in third portion, 127 
brachial, 128 

anatomy of, surgical, 128 
ligation of, above median nerve, 
131 
below median nerve, 131 
brachial, at bend of eibow, 132 
anatomy of, surgical, 132 
ligation of, 133 
carotid, common, 104 

anatomy of, surgical, 104 
ligation of, above omo-hyoid 
muscle, 107 
below omohyoid muscle, 108 
carotid, external, 110 
anat my of, surgical, 110 
ligation of. Ill 
caro-id, internal, 117 



INDEX. 



277 



Artery, carotid, internal — 

anatomy of, surgical, 117 

ligation of, 118 
dorsalis pedis, 165 

anatomy of, surgical, 165 

ligation of, 166 
facial, 114 

anatomy of, surgical, 114 

ligation of, 114 
femoral, common, 150 

anatomy of, surgical, 150 

ligation of, 154 
femoral, superficial, 154 

ligation of, at apex of Scarpa's 
triangle, 154 
in Hunter's canal, 156 
gluteal, 148 

anatomy of, surgical, 148 

ligation of, 148 
iliac, common, 143 

anatomy of, surgical, 143 

ligation of, 145 
iliac, external, 145 

anatomy of, surgical, 145 

ligation of, 146 
iliac, internal, 146 

anatomy of, surgical, 146 

ligation of, 147 
innominate, 98 

anatomy of, surgical, 98 

ligation of, 100 
lingual, 113 

anatomy of, surgical, 113 

ligation of, 114 
occipital, 116 

anatomy of, surgical, 116 

ligation of, 117 
peroneal, 171 

anatomy of, surgical, 171 

ligation of, 172 
popliteal, 156 

anatomy of, surgical, 156 

ligation of, in upper third, 159 
lower third, 160 
pudic, internal, 149 

anatomy of, surgical, 149 

ligation of, 149 
radial, 134 

anatomy of, surgical, 134 

ligati.on of, in upper third, 135 
middle third, 136 

24 



Artery, radial, ligation of — 
lower third, 136 
on outer side of wrist, 137 
anatomy of, surgical, 137 
ligation of, 137 
sciatic, 148 

anatomy of, surgical, 148 
ligation of, 149 
subclavian, 118 

anatomy of, surgical, 118 
ligation of, 122 
temporal, 115 

anatomy of, surgical, 115 
ligation of, 116 
thyroid, superior, 112 
anatomy of, surgical, 112 
ligation of, 113 
tibial, anterior, 160 

anatomy of, surgical, 160 
ligation of, in upper third, 163 
middle third, 163 
lower third, 164 
tibial, posterior, 166 

ligation of, in upper third, 168 
middle third, 170 
lower third, 170 
at the ankle, 171 
ulnar, 138 

anatomy of, surgical, 138 
ligation of, in upper half, 139 
middle of forearm, 140 
lower half, 141 
Bandages — Bandaging, 36 
arm, 59 
circular, 41 

of the abdomen, 55 
of the eyes, 43 
of the forehead, 43 
of the forearm or arm, 60 
of the neck, 49 
of the wrist, 60 
compound, 69 

crossed, of angle of the jaw, 44 
of one breast, 51 
of both breasts, 52 
of one eye, 44 
of both eyes, 44 
Desault's, 67 
figure-of 8, 42 
of ankle, 62 
anterior of chest, 50 






278 



INDEX. 



Bandaging, figure-of-8 — 

posterior of chest, 51 

of elbow, 60 

of knee, 62 

of neck and axilla, 49 

of thighs, 63 

of wrist, 60 
French spiral, 65 
general, 65 
Gibson's, 47 
head, of the, 42 
immovable, 75 
inferior extremity covering 

heel, 62 
invaginated, 70 
knotted, of the head, 45 
length of, for the body, 38 

for the hand, 39 

for the head, 38 

for the extremities, 38 
machine for rolling, 37 
method of applying, 39 
method of fastening, 39 
oblique, 41 

of forearm or arm, 61 
plaster of Paris, 76 
preparation of, 36 
recurrent, 42 

for amputations, 66 

of the head, 46 
Rhea Barton's, 48 
rolling, 37 
Scultetus, 65 
silica, 77 
simple, 36 
sling, 71 
spica, 42 

o£one or both groins, 56 

of the instep, 63 

of the shoulder, 53 

of the thumb, 59 
spiral, 41 

of the abdomen, 55 

of the chest, 54 

of the finger, 56 

of all of the fingers, 58 

of the palm, 58 
spiral-reverse, 41 

of the lower extremity, 64 

of the upper extremity, 61 
starch, 75 



the 



Bandaging — 

superior extremity, 56 

suspensory, 71 

T, 69 

tight, gangrene from. 40 

trunk, of the, 49 

Velpeau's, 67 

wet, application of, 40 
Cataplasms, 20 
Charpie, ]4 

Clove hitch, formation of, 74 
Compresses, 13 

cribriform, 15 

graduated, 16 

pyramidal, 17 
Cotton, 14 

absorbent, 14 

hygroscopic, 14 

salicylic, 14 
Director, grooved, 89 
Drainage tubes, 32 
Esmarch's bandage, 179 
Forceps, artery, 176 

dissecting, 25 

dressing, 24 
" Granny" knot, 95 
Gum tissue, 17 
Gutta-percha tissue, 17 
Handkerchief dressings, 71 
cord, 72 
cravat, 72 
oblong square, 71 
square, 71 
triangle, 72 
Incisions, 84 

angular, 84 

curvilinear, 84 

straight, 84 
Irrigation, methods of, 22 
Knife, positions of, 82 
Ligations, 82 

general considerations in, 91 

instruments used in, 89 

of special arteries, 98 

rules for, 96 
Ligatures, 90 

carbolized catgut, 32 
Lint, 13 

absorbent, 14 

antiseptic, 14 

paper lint, 14 



INDEX. 



279 



Lint — 

patent lint, 14 
Mackintosh, 32 
Maltese cross, 15 

half, 16 
Needles, 87 

ligature, 90 
Oakum, 14 
Oiled paper, 17 
Oiled silk, 17. 

Operations antiseptically performed , 
33 

upon the living and dead subject, 
87 
Plaster of Paris jacket, 79 
Plasters, 18 

Pocket case of instruments, 26 
Poultices, 20 

astringent, 21 

emollient, 20 

fermenting, 21 

flaxseed meal, 20 

method of preparing, 20 

rubefacient, 21 

stimulating. 21 
Protective antiseptic, 32 
Reef-knot, 95 
Rollers, double-headed, 38 

single-headed, 38 
Rubber cloth, 17 



Sayre's suspension apparatus, 78 
Scissors, 25 
Spatulas, 90 
Splints, 35 
Sponges, 23 

antiseptic, 33 

method of cleansing, 23 
of using, 24 
Spongio-piline, 15 
Steam spray apparatus, 31 
Surgical dressings, 13 
Sutures, 85 

carbolized silk, 33 

continued, 85 

interrupted, 85 

quilled, 85 

twisted, 85 
Tenaculum, 176 
Tenax, 15 
Tourniquet, 178 
Tow, 15 

Triangles of the neck, 102 
Waxed paper, 17 
Wool, 14 
Wounds, cleansing of, 29 

closure of, 85 

dressing of, 24 

articles required in, 28 

instruments used in dressing, 24 

rules for, 29 



